Synkope - harmlos oder gefährlich?

Syncopes: dangerous or not? Based on a case report of a patient with syncope and incomplete trifascicular block we would like to give a brief overview of pathophysiological and clinical aspects of syncope focussing on three considerations of syncope management: risk stratification in the emergency department, syncope in the setting of biand trifascicular block, and driving recommendations after a syncope. Syncopes account for up to 3% of emergency department visits. Owing to the heterogenous nature of underlying causes, initial evaluation and management of syncope is essential, but may be challenging. Identification of patients at increased risk for arrhythmias or death is crucial. Hence, predictors of worse outcome available at presentation to the emergency department have been identified and risk stratification scores validated which may be useful prognostic tools for an efficient initial triage of patients presenting after a syncopal event. Patients with syncope and bifascicular block are at increased risk for transient complete AV block, which has even been observed in the setting of negative electrophysiological studies. Hence, pacemaker implantation is indicated not only in patients with bifascicular block and documented intermittent high-grade AV block (class I), but also in the setting of bifascicular block and high suspicion of cardiac syncope (class IIa). Patients with unexplained syncope should be advised not to drive for six months. However, driving recommendations are difficult to translate into practice.