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Syncope is a frequent disorder, sometimes due to life-threatening causes. The uncertainty in its diagnosis requires a standardized approach. According to the 2018 European Society of Cardiology (ESC) guidelines, new aspects in evaluation and treatment include risk stratification and decision-making strategies during the initial evaluation in the emergency department, a reconsideration of diagnostic tests, algorithms for the treatment of reflex syncope, indications for an implantable cardioverter/defibrillator in high risk patients for sudden cardiac death, and organizational aspects such as interdisciplinary syncope units. The 2018 ESC guideline and the 2019 commentaries of the German Society of Cardiology (DGK) are an excellent and comprehensive instruction for safe, effective and efficient evaluation and therapy. However, some aspects require critical appraisal. The inadequate availability and reimbursement of pivotal diagnostic tests, such as tilt table testing and the implantable loop recorder is emphasized.