From the Guidelines
Syncope Workup The appropriate workup for syncope should start with a thorough history and physical examination to identify potential causes, as recommended by 1.
Initial Evaluation
Initial evaluation should include:
- Electrocardiogram (ECG) to detect arrhythmias or abnormality indicative of higher risk for arrhythmia, as suggested by 1
- Complete blood count (CBC), basic metabolic panel (BMP), and serum electrolyte tests to rule out metabolic causes, as recommended by 1
Further Testing
If the cause remains unclear, further testing may include:
- Echocardiogram to evaluate cardiac structure and function, as recommended by 1
- Tilt table test to assess for orthostatic intolerance or vasovagal syncope, as suggested by 1
- Holter monitor or event monitor for arrhythmia detection, as recommended by 1
- Electrophysiology study if arrhythmia is suspected, as suggested by 1
- Neurological evaluation, including imaging studies like MRI, if a neurological cause is suspected, as recommended by 1
Medication Review
Medications that may be contributing to syncope, such as antihypertensives, antiarrhythmics, or sedatives, should be reviewed and adjusted as necessary, as suggested by 1.
Referral
In cases where syncope is recurrent or of unclear etiology, referral to a cardiologist or neurologist may be necessary for further evaluation and management, as recommended by 1.
From the Research
Initial Evaluation
The initial evaluation of syncope includes:
- A careful history 2, 3, 4, 5, 6
- Physical examination, including orthostatic blood pressure measurements 4, 5
- Electrocardiography (ECG) 2, 3, 4, 5, 6
Classification of Syncope
Syncope can be classified into:
- Cardiac syncope 2, 3, 4, 5
- Reflex (neurally mediated) syncope, including vasovagal syncope, situational syncope, carotid sinus syncope, and atypical reflex syncope 2, 3, 4, 5
- Orthostatic hypotension syncope 2, 3, 4, 5
Risk Stratification
Patients with syncope should be risk-stratified into high or low-risk groups to guide further investigations and management:
- High-risk patients include those with cardiovascular or structural heart disease, history concerning for arrhythmia, abnormal ECG findings, or severe comorbidities 3, 4, 5, 6
- Low-risk patients can often be reassured with no further investigation 3, 4
Additional Testing
Additional testing should be based on the initial clinical evaluation and may include:
- Prolonged ECG monitoring 2, 3, 4, 6
- Echocardiography 2, 4
- Exercise stress testing 2
- Head-up tilt-table testing and carotid sinus massage for neurogenic reflex-mediated syncope 2
- Neuroimaging, such as head computed tomography or magnetic resonance imaging, for patients with suspected neurologic events or focal neurologic signs or symptoms 2, 4
- Laboratory tests, such as hemoglobin measurement, based on history and physical examination findings 4