Definition and classification of syNCOpe and presyncope.
-Neurally mediated syncope vs. cardiac syncope vs. orthostatic hypotension syncope.
-Patients with presyncope have similar prognoses to those with syncope and should undergo a similar evaluation” (AFP 2017)
H&P performed.
Differential Diagnosis reviewed.
Risk stratification: San Francisco Syncope Rule.
Management:
-Orthostatic vitals in all patients.
-12-lead ECG in all patients. Look for abnormal ECG findings.
-Admit to telemetry for cardiac monitoring for possible arrhythmias
-Consider Holter monitor, Event monitor, or Loop recorder as an outpatient to r/o arrhythmias.1
-Echo (TTE) to r/o structural heart disease.
-Head-up tilt table test as needed to differentiate b/n neurally mediated syncope vs. orthostatic HoTN.
-HbA1c, FLP, TSH (to risk stratify or to assess for cardiovascular risk factors)
-Urine Drug Screen.
-Neuro-check Q4H
-Bedside swallow evaluation before feeding.
-PT / OT eval
-IV Fluids, as needed.
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Key Points
- Mnemonic for the classification of syncope: syNCOpe.
- What is the difference between neurally mediated (reflex) syncope and orthostatic hypotension syncope?
- Carotid massage – will let cardiology consider performing that.
- Get EKG and orthostatic in all pre-syncope and syncope patients.
- “The treatment of neurally mediated and orthostatic hypotension syncope is largely supportive, although severe cases may require pharmacotherapy. Cardiac syncope may require cardiac device placement or ablation.”AFP
- The American Academy of Neurology says, “Do not perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.”
- Syncope with exercise (e.g. brisk walking) is a manifestation of organic heart disease in which cardiac output is fixed and doesn’t rise (or even fall) with exertion. Syncope, commonly with exertion, is reported in up to 42% of patient with severe aortic stenosis.
- Vasovagal syncope is associated with unpleasant stimuli or physiologic conditions, including sights, sounds, smells, sudden pain, sustained upright posture, heat, hunger, and acute blood loss.
- San Francisco Syncope Rule (high-risk criteria): CHESS = CHF, Hematocrit <30%, ECG abnormal, SOB, Systolic BP <90 mm Hg
- Head-up tilt table test is used to evaluate for “neurally mediated syncope, recurrent unexplained falls, frequent syncopal episodes, psychiatric disease, to distinguish between neurally mediated and orthostatic hypotension syncope, to differentiate syncope with jerking movements from seizure.”
- Orthostatic vital signs are used to evaluate for neurally mediated syncope, postural tachycardia syndrome, orthostatic hypotension syncope.
Vignettes:
- Young athlete + syncope: HOCM
- Young female patient + abdominal pain + syncope: ectopic pregnancy
- Elderly male + abdominal/flank pain + syncope: AAA
- Sudden onset severe HA + syncope: SAH
- Female patient + prodrome of nausea, sweating, warmth + syncope: vasovagal
- Malignancy + sudden onset SOB + syncope: PE
Notes
1 “Implantable loop recorders increase diagnostic yield, reduce time to diagnosis, and are cost-effective for suspected cardiac syncope and unexplained syncope.” AAFP 2017
2 According to the 2017 ACC/AHA/HRS Guidelines for Syncope,
References
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society
Am Fam Physician. 2017 Mar 1;95(5):303-312B.
Pocket Medicine, 5th Edition