The appealing title of this weighty guideline from the UK's National Institute of Health and Clinical Excellence (NICE) on the ‘Management of transient loss of consciousness (blackouts) in adults and young people’1 carries the burden of great expectation. Every physician recognises transient loss of consciousness as common yet frequently misdiagnosed. For example, in neurological practice, many people labelled and treated as having epilepsy turn out to have something else. More importantly, many unrecognised cardiac causes of blackouts are mislabelled and then mistreated as epilepsy. We clearly do need guidance to focus investigations and management in a coordinated and efficient way. For neurologists, however, this document will be a disappointment—few will get through the 429 pages plus appendices with its strong cardiological emphasis, its bare mention of epilepsy and its almost complete omission of psychogenic non-epileptic attacks. The indications for brain imaging and EEG in patients with transient loss of consciousness are not discussed. Cardiologists, by contrast, will find a document written with them in mind, heavily focused on recognising underlying cardiac disease following blackouts, promising much additional service work in specialist ECG interpretation and rapid access referral.

Transient loss of consciousness is of course very common (perhaps 30% of the population is affected at some point …