Emergency department management of patients with syncope according to the 2018 ESC guidelines: Main innovations and aspect deserving a further improvement.

The approach suggested by the 2018 ESC GL is the main road for achieving the ambitious goal "zero admission for syncope". This document has in fact introduced a clear-cut distinction between syncope associated with a definite diagnosis, which shall be managed according to the underlying condition, and the really undetermined cases, which shall be managed with prognostic stratification. ESC GL also emphasize the pivotal importance of managing patients in facilities such as ED observation syncope units or outpatient syncope clinics, as a safe alternative to admission. Moreover, they provide a table of non-syncopal causes of TLOC to be excluded, indicating the clinical features distinguishing them from syncope, clearly define the indications for additional examinations to be made after the initial evaluation and include a detailed table contains features for stratifying patients as being at high- and low-risk. However, we believe that this approach could be further improved, by especially defining criteria to identify patient neither high nor low risk, to be called at "intermediate-risk", making the prognostic stratification table easier to remember and use, by clarifying the role of laboratory tests to support the clinical judgment and by defining protocol for managing patients ED observation unit.