Syncope – mind the gap: it’s time to build bridges in the UK

Every week, patients present to emergency departments (EDs) following an episode of transient loss of consciousness (TLoC) due to syncope. It is common, affecting 40% of the population, and it constitutes 1–3% of ED visits and up to 6% of all hospital admissions.^1,2 The US Society for Academic Emergency Medicine – Guidelines for Reasonable and Appropriate Care in the Emergency Department (SAEM GRACE) review found that among ED patients, up to 50% remain undiagnosed after initial evaluation, that hospitalisation rates were highly variable, and approximately one-third of admitted patients are discharged without a definite diagnosis.³ Along with this, patients are subjected to unnecessary investigations, which contribute to escalating healthcare costs.⁴

Syncope is common, disabling, and, if mismanaged, potentially dangerous, both in terms of missed diagnoses or needless and harmful stays in hospital. Yet across health systems, it continues to fall between the cracks. It is time to build bridges: connecting emergency care, cardiology, neurology, geriatrics and acute medicine, through cohesive pathways that are early, equitable, efficient, and delivered by experts.

As Sutton and de Lange remind us, syncope is a symptom, not a diagnosis, and must be taken seriously.⁵ It should no longer be the orphan condition with no home. Despite not belonging in one specialty, a coordinated approach and collaboration should be forged between specialties.

A European benchmark: SEED exposes the variation

The recently published SEED (Management of Syncope in the Emergency Department) study provides a revealing snapshot of syncope care across Europe.⁶ In 41 EDs across 14 countries, 952 adult patients presenting with TLoC were evaluated, amounting to 1% of all ED attendances.

Findings were striking: 46% of sites had no syncope guideline; 75% lacked a dedicated outpatient clinic; and only 10% offered structured follow-up. Admission rates varied from 20% to 84%.

This variation highlights a persistent gap between evidence and delivery. Despite clear European Society of Cardiology (ESC 2018)⁷ and National Institute for Health and Care Excellence (NICE 2023)⁸ guidelines, SEED demonstrates inconsistent implementation. However, we know from the SYNERGY (SYNcope algorithms in the EmeRGgencY department with structured follow-up) trial that systematic implementation of those syncope guidelines improves diagnostic yield and reduces unnecessary testing and hospital admissions.⁹ Sutton and de Lange⁵ describe in their paper a mature example in the Netherlands, with structured pathways and specialist syncope units embedded within care systems.

Although the ESC guidelines emphasise a multi-disciplinary approach, in patients with syncope, survey data from the European Heart Rhythm Association show that cardiology departments remain the main drivers. Internal medicine, emergency medicine, geriatricians and neurology are also leading services, or as part of multi-disciplinary teams, but this can be fragmented.¹⁰ A national survey in Italy revealed that diagnostic approaches and referral practices differ between institutions, and, in many hospitals, there was a lack of consistent collaboration between the specialties (ED, cardiology, neurology), leading to fragmented care.¹¹

Syncope is everyone’s problem, and it raises questions about where we work and care for patients who present with TLoC. Who receives expert evaluation? Who is safely discharged? Who is lost to follow-up? Why is it that syncope pathways and services have not been implemented when they clearly show an increase in diagnostic accuracy, reduce costs, and improve outcomes for our patients and the systems in which we work?

The UK picture: islands of excellence

Data from the ASPIRED study revealed similar variation within the UK.¹² Among participating hospitals, 48.6% had a syncope protocol and 53.8% operated a dedicated clinic; others relied on acute medicine, cardiology, or same-day emergency care (SDEC) models.

In our own service at Queen Elizabeth University Hospital (QEUH), Glasgow, the rapid-access syncope clinic (RASCL) demonstrates what coordinated care can achieve.¹³ The QEUH pathway stratifies patients into high, intermediate, and low risk, directing those needing specialist input to RASCL. After implementation: low-risk admissions fell from 27% to 12% within one year and median length of stay dropped from three days to one. Bed occupancy fell by around 56 bed-days per month in unscheduled care.¹³ These results show that structured pathways – risk stratification with follow-up clinics and specialist review – reduce admissions, shorten stays, and maintain safety. Glasgow’s experience shows that redesigning systems can deliver tangible clinical and operational benefits for both the patient and the system.

This is not theory; it is a measurable improvement in practice and has been replicated over other centres in the UK.¹⁴

Why the gap matters

Missing a diagnosis, or failing to arrange appropriate follow-up, exposes patients to recurrent events, injury, anxiety and, at worst, preventable morbidity or mortality.⁶

For hospitals, the cost is seen in unnecessary admissions, extended length of stay, and unwarranted investigations. The SEED study underscores that many patients present with high-risk features. A delayed or inadequate evaluation represents a lost opportunity to prevent harm.

Bridging the gap: four pillars for a UK syncope ecosystem

To close the gap and start building those bridges, a national syncope strategy should rest on four pillars: early, equitable, efficient, and expert-delivered care.

Early

Risk stratification must begin at first contact, whether in primary care, by paramedics or in the ED. Key elements include: witness history, electrocardiogram (ECG), orthostatic blood pressures, and identification of red flags. Pathways and observation units should be embedded within EDs to support safe early decision-making.

Equitable

Every region should have access – locally or via networks – to a specialist syncope service. Geography, deprivation, or hospital size must not dictate quality of care. Clear referral routes from primary care, community teams, and falls services should prevent patients falling between the gaps.

Efficient

Investigations should be proportionate and evidence-based. Unnecessary imaging should be avoided. Instead, services should use ambulatory ECG monitoring, remote diagnostics and outpatient testing where appropriate. Defined performance metrics – admission rate, bed-days saved, time to diagnosis, recurrence – should track improvement.

Expert-delivered

Clinicians running these services should have those skills and be connected across the multi-disciplinary specialties. Syncope units should provide standardised, protocol-driven evaluation and have the appropriate investigative back-up. Multi-disciplinary case reviews should be routine for complex or high-risk cases.⁷

Building the bridge: practical steps

Sutton and de Lange urge us to take syncope seriously, and to take advantage of the wealth of research and guidelines in this area.

We propose several key steps, to progress this, and to add the foundations on which to build those solid key networks.

• Establish a UK Syncope Network and benchmarking. A national syncope network should define minimum standards, measure performance, and share best practice.¹⁵ A practical, evidence-based road map is required to support teams in delivery. Further to this, we need a UK benchmarking audit, similar to national audits completed for heart failure.¹⁶
• Mandate standard pathways in hospitals. All acute hospitals should implement syncope pathways with clear, fast-track referral to clinics or observation units, supported by governance frameworks and quality oversight.
• Invest in diagnostic infrastructure. Adequate access to ambulatory monitors, implantable loop recorders, tilt testing, and observation units is essential. Services must be staffed and resourced to sustain delivery.
• Scale up proven local models. The RASCL, and other such models, provide reproducible examples of success for patients and healthcare systems. Replicating and adapting such models of care could deliver significant national gains.

Conclusion: a call to action

Syncope remains one of medicine’s invisible gaps – common, costly, and too often neglected. The SEED study exposes wide variation across Europe; but within the UK, there are centres showing what is achievable.

We cannot delay in uniting these successes into a national, standardised approach that delivers early, equitable, efficient, and expert-led care for every patient.

By building bridges between specialties and services, we can ensure that syncope no longer falls through the cracks. Patients deserve this evidence-based care, and our health system is capable of better. Now is the time to act.

Conflicts of interest

None declared.

Funding

None.

References

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2. Sandhu RK, Sheldon RS. Syncope in the emergency department. Front Cardiovasc Med 2019;6:180. https://doi.org/10.3389/fcvm.2019.00180

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12. The University of Edinburgh. Usher Institute. ASPIRED study. Available at: https://usher.ed.ac.uk/edinburgh-clinical-trials/our-studies/all-current-studies/aspired-study [accessed 20 November 2025].

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15. Kenny RA, Brignole M, Dan GA et al. Syncope unit: rationale and requirement – the European Heart Rhythm Association position statement endorsed by the Heart Rhythm Society. Europace 2015;17:1325–40. https://doi.org/10.1093/europace/euv115

16. National Institute for Cardiovascular Outcomes Research (NICOR). National Heart Failure Audit (NHFA). Available at: https://www.nicor.org.uk/national-cardiac-audit-programme/heart-failure-audit-nhfa