State Ceremonial and Public Duties (SCPD) expose soldiers to extreme physiological stressors, predisposing to syncope. Despite a high incidence of syncope in military personnel, physiological responses during SCPD are unknown. Data were collected across three ceremonial parades (n = 41; 3 female, age = 24 ± 1 years, duration = 2.5 h). Parades had alternating phases of motionless standing and marching. Pre-parades, baseline cardiovascular parameters (systolic arterial pressure [SAP] and heart rate [HR]), anthropometric measures, urinary sodium, anxiety and parade perspectives were collected. Salivary steroid analyses were performed pre- and post-parade. In thirty participants (n = 10/parade; 2 female) continuous SAP, HR, respiration, postural sway and skin temperature were collected using discrete wearable technology (Astroskin) worn underneath the traditional uniform. During parades, HR and minute ventilation were elevated, with maximum HR reflecting 71 ± 1.5% of age-predicted max. Parade SAPmin was 107 ± 1.8 mmHg (range 88-125 mmHg). During prolonged motionless standing (Stand 2; 63 ± 1mins), 50% of participants experienced reduced SAP that exceeded clinical criteria for orthostatic hypotension. Lower Stand 2 SAPmin was associated with larger leg mass (r = 0.484, p = 0.012), and lower percent body fat (r = 0.523, p = 0.006). Post-parade, salivary cortisol decreased (p < 0.001) while aldosterone increased (p < 0.001). Maximum estimated core temperature was 38.6 ± 0.03 °C, indicating considerable thermal stress, with a "high" physiological stress index of 7.2 ± 0.2. Participants did not fear repercussions for fainting during SCPD, but associated it with profound stigma. This work highlights the utility of wearables in field environments. SCPD represent considerable physiological stress, with marked cardiovascular instability, and substantial thermal, orthostatic, and exercise stress. Use of evidence-based prevention measures could improve syncope outcomes during SCPD.

The autonomic nervous system regulates cardiovascular function essential for homeostasis, and its impairment contributes to disorders including neurogenic orthostatic hypotension, postural orthostatic tachycardia syndrome, and syncope. Quantifying cardiovascular autonomic physiology is therefore paramount in both clinical and research settings to support diagnosis, to mechanistically interrogate autonomic control during physiological challenge, and to test new treatments. As many autonomic abnormalities are expressed through changes in cardiac timing, blood pressure control, and hemodynamic redistribution, cardiovascular monitoring remains a cornerstone of autonomic phenotyping. In this review, we synthesize and compare technologies used to measure key cardiovascular signals relevant to autonomic function, spanning cardiac electrical activity (ECG-derived rhythm and R-R intervals for heart rate/heart rate variability), vascular pressure (intermittent versus beat-to-beat, and central versus peripheral blood pressure), and flow/volume surrogates that inform redistribution and cardiac output dynamics. Within each domain, we consider measurement approaches across invasiveness tiers, from highly invasive and implantable methods to less invasive tools and emerging wearable modalities, highlighting what each method directly measures versus estimates and the implications for interpretation. This continuum increasingly enables longer-duration and ambulatory assessments, creating opportunities to link symptoms to physiology, track dynamic treatment responses, and extend autonomic phenotyping beyond laboratories and hospitals, while highlighting ongoing needs for accuracy, robustness, calibration, and long-term stability in everyday environments.

Syncope in older adults is often multifactorial, with polypharmacy being a common and potentially modifiable factor. Benzodiazepines are prescribed for anxiety and insomnia in this population despite being associated with adverse effects, including falls, cognitive impairment, and hypotension. We present the case of a 68-year-old female patient with multimorbidity and recurrent unexplained syncope despite extensive cardiologic and neurologic evaluations. She was on diazepam therapy for anxiety as part of a complex medication regimen. A temporal relationship was observed between diazepam administration and episodes of hypotension, with systolic blood pressure dropping as low as 70 mmHg approximately three to four hours after dosing. Following stepwise dose reduction of diazepam, the frequency of syncopal episodes decreased over a four-month period, with no alternative single factor fully explaining the improvement. This case highlights the importance of medication review in older adults presenting with syncope. Benzodiazepines may contribute to clinically significant hypotension, particularly in the context of polypharmacy, and dose reduction or deprescribing may lead to clinical improvement.

Syncope and polypharmacy are prevalent in older adults and negatively affect quality of life. This study compares the impact of medication regimen complexity, the total number of medications per day as a measure of polypharmacy, and orthostatic hypotension (OH)-inducing drug burden in older adults with syncope. It also sought to determine a polypharmacy threshold warranting medication review and to identify a distinct polypharmacy phenotype among older adults with syncope and metabolic syndrome (MetS). This study included 104 patients presenting with syncope, stratified by age. Therapeutic complexity was measured using the Medication Regimen Complexity Index (MRCI), total number of medications per day, and an OH risk score (OHscore-SGLT2i). Older adults had significantly higher MRCI, total number of medications per day, and OHscore-SGLT2i than younger adults (p < 0.001), with the youngest-old and middle-old subgroups showing the highest therapeutic complexity (p < 0.05). Regression models adjusted for the comorbidity burden confirmed these findings. ROC analysis identified the total number of medications per day as the best discriminator (AUC = 0.841), with an optimal threshold of 3.5 medications. Notably, 85.7% of older adults with syncope and MetS exceeded this threshold (p < 0.001) and were significantly more likely to experience clinically significant polypharmacy with adverse outcomes (OR 18.9). Polypharmacy is the primary driver of therapeutic complexity in older adults with syncope. A threshold of four or more medications per day may prompt polypharmacy review, particularly in older adults with MetS, who may benefit most from targeted deprescribing.

Syncope in older adults is common, heterogeneous, and frequently misclassified as an unexplained fall, leading to injury, fear of recurrence, and costly, low-yield testing and hospitalization. The 2018 European Society of Cardiology (ESC) Guidelines emphasize structured initial evaluation (history with witnesses, orthostatic blood pressure, and 12-lead ECG), risk-feature-guided disposition, and targeted second-line investigations rather than routine neuroimaging or carotid duplex ultrasound. We performed a structured narrative review anchored to the ESC 2018 Guidelines, searching MEDLINE/PubMed up to February 2026 for randomized trials, observational cohorts, and systematic reviews with substantial representation of adults aged ≥65 years and extracting geriatric-relevant outcomes including injury, falls, admission, arrhythmic diagnoses, and short-term serious events. Evidence since 2018 supports the enduring value of the ESC 2018 Guidelines' framework but highlights the need for geriatric adaptation: repeated orthostatic phenotyping (including post-prandial and delayed hypotension), systematic deprescribing, and explicit integration of frailty, cognition, and trauma risk into disposition decisions. Post-2018 data strengthen mechanism-based strategies, including earlier implantable loop recorders with remote monitoring and selective pacing for tilt-induced asystolic reflex syncope, while cardioneuroablation remains investigational for most elders. We propose a pragmatic pathway prioritizing diagnostic yield, minimizing low-value testing, and aligning interventions with patient goals and functional outcomes to reduce recurrences and support safer transitions.

Lateral medullary infarction typically presents with sensory disturbance, cerebellar ataxia, and Horner's syndrome, whereas orthostatic hypotension is not generally considered a typical manifestation, but it may cause syncope. A 77-year-old man developed recurrent syncope during early mobilization following an acute right lateral medullary infarction. Head-up tilt testing demonstrated severe orthostatic hypotension with minimal heart rate response and inadequate plasma norepinephrine increase. Sequential treatment with midodrine, fludrocortisone, and droxidopa resolved the symptoms. Serial head-up tilt testing suggested a partial improvement in the orthostatic hemodynamic responses. Orthostatic hypotension should be considered in patients with lateral medullary infarction and positional symptoms, and serial head-up tilt testing may help document any changes in the orthostatic hemodynamic response.

Cardiac syncope in children is a critical risk and demands a prompt, accurate diagnosis. This study aimed to elucidate the diagnostic efficacy and clinical relevance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in distinguishing between cardiac and non-cardiac syncope in children. A prospective study was conducted in a tertiary pediatric emergency department (ED), enrolling patients who were diagnosed with syncope. Conventional cardiac biomarkers, serum NT-proBNP, telecardiography, and 12-lead electrocardiography were performed. All patients underwent echocardiography, while TILT testing and 24-h Holter monitoring were performed by a pediatric cardiologist in a subset of patients. Electroencephalography (EEG) was performed after cardiac syncope had been ruled out and the patient had been evaluated by a pediatric neurologist. Overall, 197 patients and 50 healthy children were included. Cardiac etiology was identified in 8.6% of patients, while vasovagal, idiopathic, neurologic, orthostatic, and psychogenic syncope accounted for 27.9%, 28.9%, 15.2%, 5.6%, and 7.6% of cases, respectively. The TILT test was performed on only 19.8% of patients, and 46.2% were positive. The median serum NT-proBNP levels were 437.4 ng/L, 44.5 ng/L, and 37.1 ng/L in children with cardiac syncope, non-cardiac syncope, and healthy children (p < 0.001, p = 0.008, and p = 0.971, respectively). The optimum diagnostic cut-off point for cardiac syncope in 7-18-year-old children was 145.0 ng/L, the AUROC was 0.761 (95% CI:0.589-0.934), sensitivity 64.3%, specificity 98.2%, PPV 75.0%, and NPV 97.1%. Conclusion: Serum NT-proBNP levels have been shown to be a promising biomarker for predicting cardiac syncope in children. An NT-proBNP level above 145 ng/L may help identify children at increased risk of a cardiac etiology.