Our article (1) has prompted justified and important correspondence, for which we are grateful. We agree with Diehl and Haensch: a medical history based on individual circumstances, physical examination, 12-lead ECG, and orthostatic testing are part of the basic diagnostic criteria, such as stipulated in the guidelines. Our study showed that this is often not adhered to in routine clinical practice. Our analysis showed that many patients with syncope have clinically relevant electrolyte imbalances (for example, hyponatremia) or renal failure. For this reason we think that the basic diagnostic criteria should be extended in the emergency setting to include a standardized laboratory test. A further result of our study was the warning not to regard vasovagal syncope as benign by default, as is suggested in some of the epidemiological literature. Patients with vasovagal syncope often have relevant comorbidities, which in the presence of vasovagal syncope may be associated with negative end points.

If the basic diagnostic criteria did not yield a definite diagnosis then we undertake a tilt table test in our clinical practice. In our analysis of 440 patients (1), seven were examined by using the tilt table. Two patients showed a pathological finding. We did not carry out carotid sinus massage in the extended diagnostic evaluation of syncope because the causal connection between a hypersensitive carotid sinus and an experienced syncope often remains questionable and depends on the patient’s age (2). We did not report these two pieces of information owing to space constraints and the necessary editing down of the manuscript. We wish to point out here that risk stratification of syncope patients in the emergency department should rank more highly in importance and that correct categorization of the type of syncope seems of secondary importance, at least in patients presenting to the emergency department for the first time because of syncope. Risk stratification includes the categorization into syncope that “requires investigation” and “does not require investigation,” with the latter not expected to yield any undesirable end points in the further course. This needs to be done for every patient in an emergency department, independently of the type of syncope.

We thank our correspondent for correcting the categories of syncope that we used in our manuscript, which may have added to the confusion. We used terminology and systems as gleaned from original articles, which have dealt with this topic in heterogeneous ways. Furthermore, the guideline for the investigation of syncope issued by the German Neurological Society (3), which was set out without involvement of cardiologists or emergency physicians, differs in various details from the guideline of the European Society of Cardiology (4). The latter was published only after we had conceived and analyzed the project we presented in our article. Our future studies will be based on the recommendations for the classification of syncope issued by the European Society of Cardiology.

DOI: 10.3238/arztebl.2012.0476

Sebastian Güldner

Prof. Dr. med. Harald Mang

Universität Erlangen-Nürnberg

Prof. Dr. med. Michael Christ

Klinik für Notfall- und Internistische Intensivmedizin

Klinikum Nürnberg

michael.christ@klinikum-nuernberg.de

Conflict of interest statement

Sebastian Güldner is a management trainee with the Helios Hospital Group.

Professors Mang and Christ declare that no conflict of interest exists.

1.
Güldner S, Langada V, Popp S, Heppner HJ, Mang H, Christ M: Patients with syncope in a German emergency department: description of patients and processes. Dtsch Arztebl Int 2012; 109(4): 58–65. VOLLTEXT
2.
Humm AM, Mathias CJ: Abnormal cardiovascular responses to carotid sinus massage also occur in vasovagal syncope – implications for diagnosis and treatment. Eur J Neurol 2010; 17: 1061–7. CrossRef MEDLINE
3.
Diehl R: Leitlinien für Diagnostik und Therapie in der Neurologie:
Synkopen. Stuttgart: Georg Thieme Verlag 2008; 654 ff.
4.
Moya A, Sutton R, Ammirati F, Blanc, et al. for the Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS): Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30: 2631–71. Epub 2009 Aug 27.
MEDLINE PubMed Central
1.Güldner S, Langada V, Popp S, Heppner HJ, Mang H, Christ M: Patients with syncope in a German emergency department: description of patients and processes. Dtsch Arztebl Int 2012; 109(4): 58–65. VOLLTEXT
2. Humm AM, Mathias CJ: Abnormal cardiovascular responses to carotid sinus massage also occur in vasovagal syncope – implications for diagnosis and treatment. Eur J Neurol 2010; 17: 1061–7. CrossRef MEDLINE
3. Diehl R: Leitlinien für Diagnostik und Therapie in der Neurologie:
Synkopen. Stuttgart: Georg Thieme Verlag 2008; 654 ff.
4. Moya A, Sutton R, Ammirati F, Blanc, et al. for the Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS): Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30: 2631–71. Epub 2009 Aug 27.
MEDLINE PubMed Central