Syncope resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]

Definition

Syncope is defined as a transient LOC, characterized by rapid onset, short duration and spontaneous complete recovery due to cerebral hypoperfusion.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Syncope in the Context of Transient LOC

 
 
 
 
 
 
 
Determine if there was LOC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If yes:
❑ Rapid onset?
❑ Short duration?
❑ Spontaneous complete recovery?
 
 
 
 
 
 
If no:
Cataplexy
❑ Drop attacks
❑ Falls
❑ Functional /psychogenic pseudosyncope
♦ Psychiatric evaluation
TIA of carotid origin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If no to ≥1; exclude the following before proceeding with syncope evaluation:
Coma
❑ Aborted SCD
Epilepsy
-Perform neurological evaluation
-Perform tilt testing, preferably with concurrent EEG and video monitoring if doubt of mimicking epilepsy
❑ Metabolic disorders:
Hypoglycemia
Hypoxia
Hyperventilation with hypocapnia
Intoxication
❑ Vertebrobasilar TIA
 
If yes:
❑ Transient LOC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non traumatic
 
Traumatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspect:
❑ Syncope
Seizure
❑ Psychogenic
 
 
 
 
 
 

Diagnostic Flowchart in Patients with Suspected Syncope

 
 
 
 
 
 
 
 
 
❑ Initial Assessment:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Clinical history
❑ Physical examination (including supine and standing BP measurement after 3 minutes if OH is suspected)
EKG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Syncope
 
 
 
 
 
T-LOC non syncopal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Certain diagnosis:
Treat as according
 
 
 
 
 
Uncertain etiology
 
❑ Confirm with specific test:
- EEG
- US of neck arteries
- Brain CT
- Brain MRI
OR
❑ Consult with specialist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If arrhythmic cause identified:
(EPS)
 
 
 
 
 
Risk stratification
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine if there are any high risk criteria:
❑ Severe structural or CAD
❑ Clinical orECG features suggesting arrhythmic syncope:
-Syncope during exertion or supine
-Palpitations at the time of syncope
-Family history ofSCD
-Non-sustained VT
-Conduction abnormalities with QRS >120 ms
-Sinus bradycardia
-Pre-exited QRS complex
-Prolonged or short QR interval
-Brugada pattern
-ARVC
❑ Important comorbidities:
-Severe anemia
-Electrolyte intolerance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ If yes:
High risk
 
 
 
 
 
❑ If no:
Low risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediate in-hospital monitoring:
In bed or telemetry
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk, recurrent syncopes:
❑ Cardiac or neurally mediated testst as appropriate:
-Holter if >1 episode/week
-ELR if interval between episodes <4 weeks
Delayed treatment guided by ECK documentation
 
 
 
 
 
Low risk, single syncope
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ If suspicion of structural heart disease:
Echocardiography
 
 
 
 
 
Was it in high risk setting?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If yes:
Treat as according
 
No structural heart disease
 
Yes
 
No:
No further evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tilt testing
 
 
 
 

Treatment of Syncope

 
 
 
Reflex and orthostatic intolerance
 
 
 
 
 
Cardiac
 
 
 
Unexplained and high risk SCD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unpredictable or high- frequency
 
Preictable or low frequency
 
Cardiac arrythmias SCD
 
Structural (cardiac or pulmonary)
 
i.e. CAD, HOCM, ARV, channelopathies
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider specific therapy or delayed treatment based by ECG documentation
 
Education, reassurance, avoidance of triggers
 
Specfic therapy of the culprit arrythmia
 
Treatment of underlying disease
 
Consider ICD therapy


Algorithms based in 2009 ESC Guidelines for the Diagnosis and Management of Syncope. [3]

Do's

  • Tilt testing is indicated when it is of clinical value to demonstrate susceptibility to reflex syncope to the patient.
  • Tilt testing should be considered to discriminate between reflex and OH syncope.
  • Perform tilt testing if psychiatric disease.
  • Tilt testing may be considered for differentiating syncope with jerking movements from epilepsy.
  • If syncope happened after standing up position, there should be documentation with active standing or tilt testing in order to diagnose OH.
  • Perform CSM if patient >40 years with syncope of unknown aetiology after initial evaluation.
  • If multiple unexplained falls; perform tilt testing.
  • Consider ILR before embarking on cardiac pacing in patients with suspected or certain reflex syncope presenting with frequent or traumatic syncopal episodes.
  • Evaluate neurologically if syncope is due to ANF, to evaluate underlying disease.

Don'ts

  • Don't performCSM in patients with previous TIA or stroke within the past 3 months and in patients with carotid sinus bruits (except if carotid sinus Doppler studies excluded significant stenosis.
  • Don't use tilt testing for assessment of treatment.
  • Don't perform isoproterenol tilt testing in patients with ischaemic heart disease.
  • Don't use ATP test as a diagnostic test to select patients for cardiac pacing, owing to lack of correlation with spontaneous syncope,.
  • Don't perform EPS if there is already indication for ICD in patients with ischemic heart with suspected arrhythmic cause.
  • Don't perform EPS in patients with normal ECK, no heart disease, and no palpitations.

References

  1. Khoo, C.; Chakrabarti, S.; Arbour, L.; Krahn, AD. (2013). "Recognizing life-threatening causes of syncope". Cardiol Clin. 31 (1): 51–66. doi:10.1016/j.ccl.2012.10.005. PMID 23217687. Unknown parameter |month= ignored (help)
  2. Kapoor, WN. (2000). "Syncope". N Engl J Med. 343 (25): 1856–62. doi:10.1056/NEJM200012213432507. PMID 11117979. Unknown parameter |month= ignored (help)
  3. Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A; et al. (2009). "Guidelines for the diagnosis and management of syncope (version 2009)". Eur Heart J. 30 (21): 2631–71. doi:10.1093/eurheartj/ehp298. PMC 3295536. PMID 19713422‎ Check |pmid= value (help).