1. Neurocardiogenic or vasovagal (emotional, situational or orthostatic triggers)
4. Neurological / psychiatric (5%). Neurological causes of syncope include basilar artery migraine, vestibular dysfunction and vertebrobasilar ischaemia. Psychiatric syncope is a recognised syndrome consisting of syncopal episodes found in anxiety, depression and conversion disorder that resolve with treatment of the psychiatric disorder.
5. Essential (no cause found -35-50%).
These will all be covered in turn, and separately. There are scoring systems used to help risk-stratify syncope (very important). I do like EM Basic's quick approach:
Syncope + headache= subarachnoid or intracranial hemorrhage
Syncope + neuro deficit= stroke/TIA or intracranial bleed
Syncope + confusion= seizure
Syncope + chest pain= MI, PE, or aortic dissection
Syncope + back/abdominal pain in older patient= abdominal aortic aneurysm (AAA)
Syncope + positive HCG= ectopic pregnancy
Young with Syncope R/O: Structural heart prob HOCM Elect (brugada, prolonged QT, arrhythmia) Hypoglycaemia CNS insult Abnormal Lytes #FOAMed
— Meshal AlBassam (@meshal_albassam) March 16, 2014
OESIL (Osservatorio Epidemiologico della Sincope nel Lazio) Score
- age over 65 years;
- previous history of cardiovascular disease;
- syncope without prodrome and
- abnormal ECG
The San Francisco Rule
The San Francisco rule identifies high risk patients based on the presence of the following factors:
- History of congestive cardiac failure
- Haematocrit < 30%
- Abnormal ECG
- Complaint of shortness of breath
- Systolic Blood Pressure < 90 mm Hg
The EGSYS (derived from patients enrolled in the Evaluation of Guidelines in SYncope Study 2 trial) Score
|Palpitations preceding syncope||4|
|Syncope during effort||3|
|Heart disease/ abnormal ECG||3|
|Syncope while supine||2|
|Precipitating/ predisposing factors||-1|
A completely normal ECG makes a cardiac cause of syncope other than transient arrhythmia unlikely.
Echocardiography should be performed in any patient with a cardiac murmur and to diagnose and quantify suspected heart failure. If aortic stenosis is suspected, echocardiography should be performed urgently.
Carotid sinus massage for 5 to 10 seconds with continuous ECG and blood pressure monitoring can be used to diagnose carotid sinus syndrome. It is considered positive if it produces a drop in systolic blood pressure of 50 mm Hg or a period of asystole of 3 seconds.
Ambulatory 24 hour ECG recording may be considered in patients with a high pre-test probability of arrhythmia.
Tilt table testing is not used much any more
@drsuneet @SergioPinski @MGKatz036 To me, tilts worthless in eval of syncope. Not reproducible and high false pos/neg rates.
— Westby Fisher, MD (@doctorwes) April 6, 2014
Think about all causes - 18% of patients with syncope in one study had more than one cause.
Driving - consider whether the patient should refrain from driving
Other guidelines can be found here.