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Management of Transient Loss of Consciousness: National Institute for Health and Clinical Excellence Guideline FREE

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The full report is titled “Synopsis of the National Institute for Health and Clinical Excellence Guideline for Management of Transient Loss of Consciousness.” It is in the 18 October 2011 issue of Annals of Internal Medicine (volume 155, pages 543-549). The authors are P.N. Cooper, M. Westby, D.W. Pitcher, and I. Bullock.

Ann Intern Med. 2011;155(8):I-38. doi:10.7326/0003-4819-155-8-201110180-00369
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Who developed these recommendations?

These recommendations are from the National Institute for Health and Clinical Excellence (NICE), the group that develops recommendations for the National Health Service in the United Kingdom.

What is the problem and what is known about it so far?

Transient loss of consciousness (TLoC) is defined as an episode of fainting, “blacking out,” or “passing out” in which a person suddenly loses and then quickly regains consciousness. It is common and can be frightening for the person who experiences it and for those who see the episode. Heart problems, neurologic problems, and psychological problems can be the cause. However, persons with TLoC often undergo unnecessary tests, receive incorrect diagnoses, and may get unnecessary treatments. NICE wanted to develop recommendations that would help doctors to provide good care for patients with this condition.

How did NICE develop these recommendations?

NICE used information from published studies, health economic analyses, expert opinion, and patient views.

What did the authors find?

NICE found 27 studies on strategies for the initial assessment that might help doctors predict whether the patient has a serious cause of TLoC, 15 studies of electrocardiograms in patients with TLoC, and 102 studies about more complicated heart tests for patients with TLoC. The most common cause of TLoC was vasovagal syncope, or an “uncomplicated faint.” This often occurs during prolonged standing and can also be triggered by pain or another stressful event; the patient often reports feeling sweaty, warm, or dizzy right before fainting. If TLoC is due to seizure, the patient usually has jerking movements, tongue biting, confusion upon awakening, or other seizure symptoms. Patients with a very slow or abnormal heart beat after TLoC may have a serious heart condition.

What does NICE recommend that patients and doctors do?

The guideline includes many specific recommendations, but the main ones are summarized here.

Evaluation of TLoC should begin with a history, a physical examination, and electrocardiography.

Patients with TLoC due to an uncomplicated faint have a normal examination and electrocardiogram and often report that TLoC happened during prolonged standing; a painful or stressful event; and after feeling sweaty, warm, or dizzy. Further testing and referral are not necessary.

Patients with TLoC and seizure symptoms should see a neurologist for further evaluation.

Patients with a slow or an abnormal heart rate during or after TLoC should be evaluated for heart problems.

Doctors should consider heart monitoring if an abnormal heart rhythm is suspected or events are frequent.

What are the cautions related to these recommendations?

These recommendations may change when new studies become available.





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