Pediatric Syncope: An Examination of Diagnostic Processes, Therapeutic Approaches and the Role of the Tilt Test: Insights from an 18-Year Single-Center Experience

<b>Objectives:</b> Syncope is a common cause of the transient loss of consciousness, with neurally mediated syncope (NMS) and particularly vasovagal syncope (VVS) being the most prevalent types among older children and adolescents. VVS is primarily caused by heightened parasympathetic activity triggered by emotional or postural stimuli, resulting in a temporary disruption of circulation. Although anamnesis and physical examination play key roles in diagnosing VVS, additional diagnostic methods are necessary in unclear cases. This study aims to evaluate the long-term outcomes of pediatric patients with syncope, focusing on clinical characteristics, diagnosis, and treatment approaches. <b>Methods:</b> A retrospective analysis was conducted on 455 pediatric patients aged 8-21 years who presented with syncope at our cardiology clinic between 2005 and 2023. Patients diagnosed with cardiac syncope, epilepsy, or postural orthostatic tachycardia syndrome (POTS) were excluded. The remaining 283 patients were categorized into two groups: those with confirmed VVS-based on a comprehensive evaluation, including medical history, physical examination, and electrocardiography-and those suspected of VVS who lack a confident diagnosis after an initial assessment requiring tilt table testing. Clinical features, diagnostic methods, and treatment outcomes were analyzed. <b>Results:</b> The study cohort had a mean age of 13.5 ± 1.6 years, with a female predominance of 69%. Among patients who underwent tilt table testing (TTT), 74.8% exhibited a positive response, with mixed-type syncope being the most prevalent (51%). Syncope recurrence was significantly higher in the TTT group (54%) compared to the clinically diagnosed group (15%) (<i>p</i> < 0.001). Relapse risk was strongly associated with the syncope subtype, particularly cardioinhibitory type 2B (OR: 2.3, 95% CI: 1.1-4, <i>p</i> < 0.01), and episode frequency (OR: 1.7, 95% CI: 1.3-2.5, <i>p</i> = 0.03). Beta-blocker therapy was selectively administered and demonstrated a reduced relapse risk in a univariate analysis. <b>Conclusions:</b> VVS is a significant health issue in pediatric patients and the therapeutic modalities available encompass various interventions, including modifications to lifestyle, adequate hydration, and pharmacological therapies. TTT was found to be an effective diagnostic tool for identifying high-risk patients and is recommended for appropriate cases in pediatric VVS diagnosis in accordance with the guidelines, with the objective of refining therapeutic methodologies and ultimately augmenting patient prognoses.