Syncope and the heart: When to suspect and how to act?

Syncope is a common clinical problem affecting up to 40% of individuals over a lifetime. Most cases, especially neurocardiogenic (ie, vasovagal, reflex-mediated) syncope, are benign. However, cardiac causes, accounting for roughly 10%, carry a significantly higher risk of morbidity and mortality, underscoring the need for timely diagnosis and management. Accordingly, this review focuses primarily on the evaluation and management of cardiac syncope. The cornerstone of evaluation for any patient presenting with syncope remains a detailed history and physical examination, which guide selective use of diagnostic testing such as echocardiography, ambulatory monitoring and exercise testing. Routine indiscriminate testing offers limited diagnostic yield while significantly increasing cost. Decisions regarding hospital admission should be individualised based on risk features, stability and availability of close outpatient follow-up, as not all admissions improve outcomes. Treatment strategies vary depending on aetiology. Emerging technologies including artificial intelligence and wearable devices offer promise for improving diagnosis, risk stratification and monitoring. Future research should focus on refining admission criteria, optimising diagnostic pathways and validating novel digital and interventional approaches to enhance individualised care for patients with suspected cardiac syncope.