Reflex syncope is defined as a transient loss of consciousness due to a neurally mediated reflex causing sudden-onset vasodilation and bradycardia, leading to a steep decrease in blood pressure and cerebral hypoperfusion.1 According to the current European Society of Cardiology syncope guidelines, reflex syncope can be broadly classified into four groups: vasovagal syncope (VVS), situational syncope, carotid sinus syndrome and non-classical forms of syncope.1

Individuals with VVS and situational syncope are generally regarded to be at low risk of serious adverse outcomes, such as premature death, cardiac arrhythmias, pacemaker implantation or traumatic syncope recurrences. Thus, once the aetiology is established, further diagnostic tests are seldom performed.1 Both VVS and situational syncope are triggered by specific stimuli, for VVS common triggers include orthostatic challenge or emotional factors (fear, blood phobia, etc), whereas situational syncope may be provoked by micturition, defecation, swallowing, coughing, laughing, or diagnostic procedures with different endoscopes.2

During recent years, VVS has been increasingly studied, whereas few studies have examined clinical features and outcomes in patients with situational form.2 In this issue, an Italian retrospective, single-centre study by Russo et al 3 assessed clinical characteristics in 246 patients with situational syncope who underwent tilt testing, of whom 121 had isolated situational and 125 combined situational syncope and VVS, compared with 1039 patients with VVS only. Notably, this is one of the largest studies to date, to evaluate tilt test sensitivity and responses among patients with situational syncope.2

Interestingly, …