In the syncopal patient, it is important to determine if the cause is cardiac or noncardiac. A goal-directed diagnostic approach should be employed, depending on the results of the initial history and physical examination. Invasive tests should be performed only following a reasonable screening with noninvasive tests. In suspected cardiac syncope, an electrophysiologic study can be informative and should be performed if the arrhythmia cannot be documented electrocardiographically during the patient's symptoms. Appropriate therapy should be initiated once a confirmatory diagnosis has been made. Empirical treatment with antiepileptics, antiarrhythmics or pacemakers should be refrained from if at all possible. Spontaneous remission of symptoms can frequently occur, although the mechanism for this has not been determined.
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