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Decision-makers will need a distillation of the best reasons and their implications, and guidance on how to weight reasons, neither of which this systematic review provides. There is need for research to construct a suitable measure of quality and determine how best to distil. For the reasons given above, distillation should occur only after a systematic review such as this one has captured all the published reasons and how they have been used. The systematic review remains an essential ingredient of decision-makers’ brief for the reasons above and because of decision-makers’ need to check the distillation and its legitimacy.

While we did not collect data on the quality of reasons, our impressions suggest scope for improvement. A small number of publications seemed excellent e.g. ( Merritt and Grady, 2006 ; Lavery, 2008 ). However, the authors of many interpretations of reasons did not express awareness of some or any interpretations. Some reasons were presented unclearly and many were discussed only briefly or not at all. There has been minimal or no influence on the PTA literature of analyses of social or distributive justice, autonomy or just health care ( Dworkin, 2000 ; Daniels, 2008 ) or distinctions in economics between types of cost. Some publications appear unaware of theories of exploitation such as ( Wertheimer, 1999 ; Wertheimer, 2008 ). The three most frequently-referenced instruments require PTA sometimes, ( CIOMS, 1982 ; CIOMS, 1983 ; CIOMS, 1993 ; National Bioethics Advisory Commission Group, 2001 ; CIOMS, 2002 ; Nuffield Council on Bioethics Group, 2002 ) yet others impose more demanding obligations ( The European Group on Ethics in Science and New Technologies to the European Commission, 2003 ). Differences in instruments referenced may explain why some (11) legality Reason Mentions were used for the view that PTA should be ensured and others (18) for the view that PTA need not be ensured. While some inter-publication differences regarding the interpretation, implications or persuasiveness of exploitation , reciprocity , role and responsiveness appeared grounded in awareness of different interpretations of reasons or their implications, we cannot rule out that other differences are due to lack of imagination compounded by ignorance of relevant literature. We believe that, in general, systematic review of reasons will improve authors’ awareness of the need to consider reasons’ alternative interpretations and implications.

legality exploitation responsiveness

Furthermore, many publications omitted to indicate the strength of reasons relative to that of other reasons or to establishing the conclusion in the absence of defeating reasons. Some reasoning appeared invalid. For example, some reasons why PTA need not be ensured showed, at most, why specific agents , e.g. sponsors, need not ensure PTA.

The document aims to be patient-orientated and focused on therapy, and to reduce the risk of recurrence and the life-threatening consequences of syncope recurrence. For this purpose, even in the absence of strong evidence from trials, we give as much advice as possible on the most appropriate therapy based on the practical expertise of the members of the Task Force (‘Our patients seek solutions, not only explanations’). When possible, we provide therapeutic and decision-making algorithms.

Finally, we recognize that one major challenge in syncope management is the reduction of inappropriate admissions and inappropriate use of tests while maintaining the safety of the patient. We give strong focus to pathways and organizational issues (‘We have the knowledge; we need to apply it’). In particular, we propose a care pathway for the management of patients with TLOC from their arrival in the emergency department (ED), and give practical instructions on how to set up outpatient syncope clinics (syncope units) aimed at reducing hospitalization, under- and misdiagnoses, and costs.

The changes in recommendations made in the 2018 version compared with the 2009 version, the new recommendations, and the most important new/revised concepts are summarized in Figure 1 .

Figure 1
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What is new in the 2018 syncope Guidelines? AA = antiarrhythmic; AF = atrial fibrillation; ARVC = arrhythmogenic right ventricular cardiomyopathy; CSM = carotid sinus massage; ECG = electrocardiogram; ED = emergency department; LVEF = left ventricular ejection fraction; EPS = electrophysiological study; HCM = hypertrophic cardiomyopathy; ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; OH = orthostatic hypotension; PCM = physical counter-pressure manoeuvres; POTS = postural orthostatic tachycardia syndrome; PPS = psychogenic pseudosyncope; SNRT = sinus node recovery time; SU = syncope unit; SVT = supraventricular tachycardia; VT = ventricular tachycardia.

Figure 1
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What is new in the 2018 syncope Guidelines? AA = antiarrhythmic; AF = atrial fibrillation; ARVC = arrhythmogenic right ventricular cardiomyopathy; CSM = carotid sinus massage; ECG = electrocardiogram; ED = emergency department; LVEF = left ventricular ejection fraction; EPS = electrophysiological study; HCM = hypertrophic cardiomyopathy; ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; OH = orthostatic hypotension; PCM = physical counter-pressure manoeuvres; POTS = postural orthostatic tachycardia syndrome; PPS = psychogenic pseudosyncope; SNRT = sinus node recovery time; SU = syncope unit; SVT = supraventricular tachycardia; VT = ventricular tachycardia.

Central illustration
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New/revised concepts in the management of syncope. ECG = electrocardiogram; ED = emergency department; ICD = implantable cardioverter defibrillator; SCD = sudden cardiac death.

Central illustration
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New/revised concepts in the management of syncope. ECG = electrocardiogram; ED = emergency department; ICD = implantable cardioverter defibrillator; SCD = sudden cardiac death.

Syncope is defined as TLOC due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery.

Table 5.

Relative risks of astrocytoma/glioma by levels of estimated cumulative magnetic field exposure (four separate analyses), 48 768 employees first hired in power stations in period 1952–82, 1973–2010

RR, relative risk or rate ratio.

Cancer registration with morphology code ICD-0 938-948.

One year refers to a working year, ~250 eight-hour shifts.

Analysed simultaneously with sex and attained age (5-year age groups).

Analysed simultaneously with sex, attained age, calendar period (5-year periods) and negotiating body (National Joint Managerial (NJM) and National Joint Board (NJB); National Joint Council (NJC); National Joint Industrial Council (NJIC) and National Joint Building and Civil Engineering Committee (NJ(BC)E)).

Five exposure categories scored by the mean value in each category, namely 0.76, 3.72, 7.27, 13.92 and 38.50 μT year.

Five exposure categories scored by the mean value in each category, namely 0.71, 3.70, 7.25, 13.75 and 37.82 μT year.

Five exposure categories scored by the mean value in each category, namely 0, 0.19, 1.11, 3.29 and 12.26 μT year.

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Table 5.

Relative risks of astrocytoma/glioma by levels of estimated cumulative magnetic field exposure (four separate analyses), 48 768 employees first hired in power stations in period 1952–82, 1973–2010

RR, relative risk or rate ratio.

Cancer registration with morphology code ICD-0 938-948.

One year refers to a working year, ~250 eight-hour shifts.

Analysed simultaneously with sex and attained age (5-year age groups).

Analysed simultaneously with sex, attained age, calendar period (5-year periods) and negotiating body (National Joint Managerial (NJM) and National Joint Board (NJB); National Joint Council (NJC); National Joint Industrial Council (NJIC) and National Joint Building and Civil Engineering Committee (NJ(BC)E)).

Five exposure categories scored by the mean value in each category, namely 0.76, 3.72, 7.27, 13.92 and 38.50 μT year.

Five exposure categories scored by the mean value in each category, namely 0.71, 3.70, 7.25, 13.75 and 37.82 μT year.

Five exposure categories scored by the mean value in each category, namely 0, 0.19, 1.11, 3.29 and 12.26 μT year.

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Findings for meningioma risks in power station workers are shown in Table 6 . This analysis is based on 34 incident cases of meningioma. There are no statistically significant positive trends of disease risk with exposure, but point estimates of risk for distant exposures are somewhat raised for the three highest exposure categories. Findings were little different with or without adjustment for calendar period and socio-economic status.

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