{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T11:40:54Z","timestamp":1789472454247,"version":"build-2803163510"},"reference-count":26,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2023,3,29]],"date-time":"2023-03-29T00:00:00Z","timestamp":1680048000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Heart Centre, Department of Cardiology, Amsterdam University Medical Centre"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Objective: A substantial number of patients with a transient loss of consciousness (T-LOC) are referred to a tertiary syncope unit without a diagnosis. This study investigates the final diagnoses reached in patients who, on referral, were undiagnosed or inaccurately diagnosed in secondary care. Methods: This study is an in-depth analysis of the recently published Fainting Assessment Study II, a prospective cohort study in a tertiary syncope unit. The diagnosis at the tertiary syncope unit was established after history taking (phase 1), following autonomic function tests (phase 2), and confirming after critical follow-up of 1.5\u20132 years, with the adjudicated diagnosis (phase 3) by a multidisciplinary committee. Diagnoses suggested by the referring physician were considered the phase 0 diagnosis. We determined the accuracy of the phase 0 diagnosis by comparing this with the phase 3 diagnosis. Results: 51% (134\/264) of patients had no diagnosis upon referral (phase 0), the remaining 49% (130\/264) carried a diagnosis, but 80% (104\/130) considered their condition unexplained. Of the patients undiagnosed at referral, three major causes of T-LOC were revealed: reflex syncope (69%), initial orthostatic hypotension (20%) and psychogenic pseudosyncope (13%) (sum &gt; 100% due to cases with multiple causes). Referral diagnoses were either inaccurate or incomplete in 65% of the patients and were mainly altered at tertiary care assessment to reflex syncope, initial orthostatic hypotension or psychogenic pseudosyncope. A diagnosis of cardiac syncope at referral proved wrong in 17\/18 patients. Conclusions: Syncope patients diagnosed or undiagnosed in primary and secondary care and referred to a syncope unit mostly suffer from reflex syncope, initial orthostatic hypotension or psychogenic pseudosyncope. These causes of T-LOC do not necessarily require ancillary tests, but can be diagnosed by careful history-taking. Besides access to a network of specialized syncope units, simple interventions, such as guideline-based structured evaluation, proper risk-stratification and critical follow-up may reduce diagnostic delay and improve diagnostic accuracy for syncope.<\/jats:p>","DOI":"10.3390\/jcm12072562","type":"journal-article","created":{"date-parts":[[2023,3,29]],"date-time":"2023-03-29T01:33:00Z","timestamp":1680053580000},"page":"2562","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":14,"title":["Syncope Diagnosis at Referral to a Tertiary Syncope Unit: An in-Depth Analysis of the FAST II"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9522-2455","authenticated-orcid":false,"given":"Jelle S. Y.","family":"de Jong","sequence":"first","affiliation":[{"name":"Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-1784-9558","authenticated-orcid":false,"given":"Steven","family":"van Zanten","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Reinier de Graaf Gasthuis, 2625 AD Delft, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roland D.","family":"Thijs","sequence":"additional","affiliation":[{"name":"Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands"},{"name":"Department of Neurology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ineke A.","family":"van Rossum","sequence":"additional","affiliation":[{"name":"Department of Neurology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark P. M.","family":"Harms","sequence":"additional","affiliation":[{"name":"Department of Internal and Emergency Medicine, University Medical Centre Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8122-7017","authenticated-orcid":false,"given":"Joris R.","family":"de Groot","sequence":"additional","affiliation":[{"name":"Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5710-1094","authenticated-orcid":false,"given":"Richard","family":"Sutton","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital Campus, Imperial College, London SW7 6LY, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederik J.","family":"de Lange","sequence":"additional","affiliation":[{"name":"Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,3,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1330","DOI":"10.1161\/CIRCULATIONAHA.112.138396","article-title":"Syncope","volume":"127","author":"Saklani","year":"2013","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"823","DOI":"10.1093\/europace\/eum104","article-title":"Daily, weekly, monthly, and seasonal patterns in the occurrence of vasovagal syncope in an older population","volume":"9","author":"Boer","year":"2007","journal-title":"Europace"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1111\/joim.12450","article-title":"Great expectations: What patients with unexplained syncope desire","volume":"279","author":"Wieling","year":"2016","journal-title":"J. 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