To summarise the key steps in the reflex syncope workup.

To present currently available treatments for reflex syncope.

To underline the role of non-pharmacological therapy in reflex syncope.

To introduce cardioneuroablation as a new emerging therapy for reflex syncope.

In the era of evidence-based guidelines, updated frequently by various cardiac societies, and numerous very interesting and high-quality review papers published in peer-reviewed journals, writing an article on state of the art on any topic is a difficult task. How not to repeat the guidelines and well-known facts? One solution is to give more personal view, obviously based on objective knowledge, and to provide useful algorithms as well as interesting original tracings.

Assessment and management of reflex syncope is an important topic because it is frequently encountered in the general population (40% of females and 20% of males faint at least once during their life), is usually benign but may significantly decrease the quality of life and may be effectively treated in the majority of subjects.

Syncope is a transient loss of consciousness (TLOC) due to global cerebral hypoperfusion. Symptoms occur due to a sudden reduction in cardiac output and when systolic blood pressure falls below 60 mm Hg, brain autoregulation fails and syncope occurs. Syncope has to be differentiated from other forms of TLOC such as seizures, pseudopsychogenic pseudosyncope, stroke, subclavian artery steel syndrome, insufficiency of vertebral arteries, metabolic comas and other causes.

The main three forms of syncope include (1) reflex syncope, known also as neurocardiogenic syncope, (2) orthostatic hypotension and (3) cardiogenic syncope which usually occurs due to cardiac arrhythmia but sometimes also due to structural heart disease which reduces cardiac output. The most frequent form of reflex syncope is vasovagal reaction, followed by situational syncope and carotid sinus syndrome (figure 1).

Forms of transient loss of …