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Click on boxes to expand/collapse detailed information.               Characterize symptoms                                                                     Medication history                                                           Past medical history                                                           Possible triggers                                                           Physical examination                                                           Labs and tests                                                           Imaging studies                                                           Diagnostic features                                                                                         Syncope                   Non syncope loss of consciousness                                                                     Known etiology ❑ Cardiovascular ❑ Orthostatic hypotension ❑ Reflex         Unknown etiology Determine if there are any high risk criteria:         Consider additional tests                                                                             High risk       low risk   Consider alternative diagnoses                                                                               Immediate in-hospital monitoring       Recurrent syncopes       Single syncope                                                                             If suspicion of structural hear disease: ❑ Order an echocardiography           Was it in high risk setting? ❑ Potential risk of physical injury ❑ Occupational implications                                                                                                                 Structural heart disease present Treat accordingly         No structural heart disease   Yes   No: No further evaluation                                                                                               Tilt testing

==Characterize symptoms== ❑ Loss of consciousness (LOC) ❑ Rapid or slow onset ❑ Short or long duration ❑ Spontaneous complete recovery or incomplete recovery ❑ Prodrome: ❑ Diaphoresis ❑ Nausea ❑ Lightheadedness ❑ Pallor ❑ Warmth ❑ Blurry vision ❑ Chest pain (suggestive of cardiovascular syncope) ❑ Palpitations ❑ Position prior to LOC: ❑ Supine (suggestive of cardiovascular syncope) ❑ Supine to erect posture (suggestive of orthostatic hypotension or reflex syncope) ❑ Prolonged standing (suggestive of reflex syncope) ❑ Activity prior to LOC: (suggestive of cardiovascular or reflex syncope) ❑ Driving ❑ Machine operation ❑ Flying ❑ Competitive athletics ❑ Bowel or bladder incontinence (suggestive of reflex syncope) ==Inquire about medications intake:== ❑ Nitrates ❑ Diuretics ❑ Antiarrhythmic ❑ Alpha blocker ❑ Beta blocker ❑ ACE inhibitors or ARB ❑ Hydralazine ❑ Ethanol ❑ Benzodiazepines ❑ Antipsychotics ❑ Tricyclic antidepressants ❑ Barbiturates ==Obtain a detailed past medical history:== ❑ Previously healthy ❑ Previous syncope episodes ❑ Time since previous episode ❑ Number of previous episodes ❑ Cardiovascular disease: ❑ Arrhythmia ❑ Heart block (LBBB, RBBB) ❑ Valvular heart disease ❑ Heart failure ❑ Hypertrophic cardiomyopathy ❑ Cardiac tumor ❑ Neurological diseases: ❑ Parkinson's disease ❑ Diabetic neuropathy ❑ Metabolic disorders (diabetes) ❑ Recent trauma ==Identify possible triggers:== Suggestive of reflex syncope ❑ Emotional stress ❑ Crowded places (agoraphobia) ❑ Warm weather ❑ Prolonged standing ❑ Cough ❑ Micturition ❑ Defecation ❑ Swallowing ❑ Head motion ❑ Arm motion ❑ Shaving Suggestive of cardiovascular or orthostatic hypotension ❑ Trauma ❑ Change in position ❑ Fatigue ❑ Exertion Examine the patient Vitals ❑ Heart rate ❑ Irregular rhythm (suggestive of AF) ❑ Tachycardia (suggestive of orthostatic hypotension, cardiovascular or reflex syncope) ❑ Bradycardia (suggestive of cardiovascular syncope) ❑ Blood pressure: ❑ Measure in both arms, while standing and supine ❑ Orthostatic hypotension (Fall in systolic BP ≥ 20 mmHg and/or in diastolic BP of at least≥ 10 mmHg between the supine and sitting BP reading) ❑ Hypertension (suggestive of cardiovascular syncope) ❑ Respiratory rate ❑ Tachypnea (suggestive of reflex syncope) Respiratory ❑ Rales (suggestive of HF) Cardiovascular ❑ Palpitations (suggestive of arrhythmia) ❑ Carotid bruits (suggestive of cardiovascular syncope) ❑ Murmurs: ❑ Aortic stenosis: crescendo-decrecendo systolic ejection murmur best heard at the upper right sternal border ❑ Pulmonary stenosis: systolic ejection murmur best heard at the left second intercostal space ❑ Heart sounds ❑ Loud P2 (suggestive of pulmonary hypertension) Neurologic ❑ Focal abnormalities (suggestive of stroke or cerebral mass) ❑ Hemiparesis ❑ Vision loss ❑ Aphasia ❑ Hypertonia ❑ Glasgow coma scale ❑ Signs suggestive of Parkinson's disease: ❑ Tremor ❑ Rigidity ❑ Bradykinesia/Akinesia ❑ Postural instability ❑ Shuffling gait ==Order labs and tests== ❑ EKG (most important initial test) ❑ Myocardial infarction ❑ Tachyarrhythmia ❑ Heart block ❑ Bradyarrhythmia ❑ Long or short QT ❑ Bradyarrhythmia ❑ Electrolytes ❑ Hyponatremia ❑ Hypernatremia ❑ Hypokalemia ❑ Glucose (rule out hypoglycemia) ❑ ABG ❑ Hypoxia ❑ Hypocapnea (suggestive of tachypnea, rule out psychiatric disease) ==Order imaging studies== ❑ Echocardiography in case of: ❑ Structural heart disease ❑ Myocardial infarction ❑ Cardiac valve disease ❑ Head CT in case of: ❑ Head trauma ❑ TIA ==Confirm diagnosis of syncope== Must have this 3 characteristics: ❑ Short duration ❑ Rapid onset ❑ Complete spontaneous recovery Diagnostic criteria ❑ Cardiovascular ❑ Arrhythmia and cardiac ischemia-related syncope is diagnosed by EKG specific findings (Class I; Level of Evidence: C) ❑ Cardiovascular syncope is diagnosed when syncope presents with structural heart disease (Class I; Level of Evidence: C) ❑ Orthostatic hypotension (OH) ❑ Diagnosed when syncope occurs after standing up and there is documentation of OH. (Class I; Level of Evidence: C) ❑ Reflex ❑ Vasovagal syncope: if is precipitated by emotional distress and is associated with typical prodrome. (Class I; Level of Evidence: C) ❑ Situational syncope: if occurs during or after specific triggers. (Class I; Level of Evidence: C) Risk stratification Determine if there are any high risk criteria: ❑ Severe structural heart disease ❑ CAD ❑ Clinical or ECG features suggesting arrhythmic syncope: ❑ Syncope during exertion or supine ❑ Palpitations at the time of syncope ❑ Family history of SCD ❑ Non-sustained VT ❑ Conduction abnormalities with QRS >120 ms ❑ Sinus bradycardia ❑ Pre-excited QRS complex ❑ Long or short QT ❑ Brugada pattern ❑ ARVC ❑ Important comorbidities: ❑ Severe anemia ❑ Electrolyte disturbance Consider alternative diagnoses: ❑ With loss of consciousness: ❑ Coma (Glasgow coma scale < 8, profound state of unconsciousness) ❑ Sudden cardiac arrest (absence of pulse) ❑ Epilepsy (inquire past medical history) ❑ Findings: aura, prolonged confusion, muscle ache, ❑ Perform neurological evaluation (Class I; Level of Evidence: C) ❑ Perform tilt testing (Class IIb; Level of Evidence: C) , preferably with concurrent EEG and video monitoring if doubt of mimicking epilepsy ❑ Intoxication ❑ Vertebrobasilar TIA ❑ Without loss of consciousness: ❑ Cataplexy ❑ Drop attacks ❑ Functional /psychogenic pseudosyncope ❑ Perform a psychiatric evaluation (Class I; Level of Evidence: C). ❑ TIA of carotid origin Consider alternative diagnoses: ❑ With loss of consciousness: ❑ Coma (Glasgow coma scale < 8, profound state of unconsciousness) ❑ Sudden cardiac arrest (absence of pulse) ❑ Epilepsy (inquire past medical history) ❑ Findings: aura, prolonged confusion, muscle ache, ❑ Perform neurological evaluation (Class I; Level of Evidence: C) ❑ Perform tilt testing (Class IIb; Level of Evidence: C) , preferably with concurrent EEG and video monitoring if doubt of mimicking epilepsy ❑ Intoxication ❑ Vertebrobasilar TIA ❑ Without loss of consciousness: ❑ Cataplexy ❑ Drop attacks ❑ Functional /psychogenic pseudosyncope ❑ Perform a psychiatric evaluation (Class I; Level of Evidence: C). ❑ TIA of carotid origin ❑ Immediate in-hospital monitoring (in bed or telemetry) to look for abnormalities suggestive of arrhythmic syncope (Class I; Level of Evidence: B). ==Recurrent syncopes== Cardiac or neurally mediated tests as appropriate: ❑ Holter if > 1 episode/week (Class I; Level of Evidence: B). ❑ External loop recorder (ELR) if interval between episodes < 4 weeks (Class IIa; Level of Evidence: B). ❑ Carotid sinus massage in patients > 40 years with uncertain syncopal etiology (Class I; Level of Evidence: B). Contraindicated in patients with previous TIA or stroke in the past 3 months. Contraindicated in patients with carotid bruits. ==Diagnostic criteria== ❑ Induction of reflex hypotension or bradycardia with reproduction of syncope is diagnostic for reflex syncope (Class I; Level of Evidence: B). ❑ Induction of progressive orthostatic hypotension with or without symptoms is diagnostic for orthostatic hypotension (Class I; Level of Evidence: B).

Drug	Adult dosage
Inhaled Short Acting β Agonists (SABA)
Albuterol/Bitolterol/Pirbuterol a) Nebulizer solution b) MDI	♦ 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed or 10-15 mg/hour continuously. ♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Levalbuterol a) Nebulizer solution b) MDI	♦ 1.25-2.5 mg every 20 mins for 3 doses, then 1.25-5 mg every 1-4 hours as needed. ♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Anticholinergics
Ipratropium bromide a) Nebulizer solution b) MDI	♦ 0.5 mg every 20 mins for 3 doses, then as needed. ♦ 8 puffs every 20 mins as needed for upto 3 hours.
Ipratropium with albuterol a) Nebulizer solution (each 3 ml containing 0.5 mg ipratropium and 2.5 mg albuterol) b) MDI (each puff contains 18 mcg ipratropium and 90 mcg albuterol)	♦ 3 ml every 20 mins for 3 doses, then as needed. ♦ 8 puffs every 20 mins as needed for 3 hours
Systemic corticosteroids
Prednisone/Prednisolone/Methylprednisolone	♦ 40-80 mg/day in 1 or 2 divided doses until peak expiratory flowrate (PEF) reaches 70% of personal best.

Clinical course	Unstable
Physical examination	Signs of heart failure
Functional class	IV
6MWD	Less than 400 m
Echocardiogram	RV Enlargement
Hemodynamics	RAP high CI low
BNP	Elevated/Increasing
Treatment	Intravenous prostacyclin and/or combination treatment
Frequency of evaluation	Q 1 to Q 3 months
FC assessment	Every clinic visit
6MWT	Every clinic visit
Echocardiogram2	Q 6 to Q 12 months/center dependent
BNP	center dependent
RHC	Q 6 to Q 12 months or clinical deterioration