From the Guidelines
For an inpatient workup of syncope, the initial evaluation should include a careful history, physical examination, including orthostatic blood pressure measurements, and a standard electrocardiogram (ECG) 1. The diagnostic strategy is based on the initial evaluation, and differentiating true syncope from non-syncopal conditions is crucial. The following key steps should be considered:
- Obtain a detailed history and physical examination, including orthostatic vital signs.
- Perform a 12-lead ECG to assess for arrhythmias or conduction abnormalities.
- Order basic laboratory tests: complete blood count, basic metabolic panel, and cardiac enzymes.
- Consider additional cardiac testing based on initial findings:
- Echocardiogram to evaluate structural heart disease, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.
- Continuous cardiac monitoring for 24-48 hours.
- Exercise stress test if exertional syncope is suspected.
- Neurological evaluation:
- CT or MRI of the brain if neurological causes are suspected.
- EEG if seizure activity is a concern.
- Tilt table test for patients with recurrent syncope and suspected vasovagal etiology.
- Carotid sinus massage in patients over 50 years old without contraindications. It is essential to tailor the workup based on the patient's age, medical history, and presenting symptoms, and to ensure patient safety during testing, especially for procedures like tilt table tests or carotid sinus massage 1.
From the Research
Inpatient Evaluation for Syncope
The inpatient evaluation for syncope is a crucial process that aims to identify the underlying cause of the condition and provide appropriate management. According to 2, a retrospective review of patients with suspected syncope found that routine inpatient syncope workup has a low yield, and diagnostic workup should be ordered based on clinical information rather than a standardized workup for all patients.
Diagnostic Approach
The diagnostic approach to syncope typically involves a careful history, physical examination, and electrocardiograms, as stated in 3. The initial evaluation provides an estimation of risk and directs whether inpatient or outpatient evaluation is appropriate. The key to syncope is in the story as told by the patient and a bystander, since this drives both risk assessment and diagnostic testing, as mentioned in 4.
Risk Stratification
Risk stratification is an essential step in the evaluation of syncope, as it helps to identify patients with life-threatening conditions and those with red flags indicating an increased risk of sudden death, as stated in 5. The European Society of Cardiology syncope guidelines recommend an initial syncope workup based on detailed patient's history, physical examination, supine and standing blood pressure, resting ECG, and laboratory tests, including cardiac biomarkers, where appropriate.
Investigation and Management
The investigation of syncope is challenging, and physicians have an ever-increasing array of diagnostic tools at their disposal, as mentioned in 4. The key is to use a thoughtful and systematic approach to the investigation of syncope, which optimizes the diagnostic yield but also ensures efficient usage of limited health care resources. According to 6, patients with life-threatening causes of syncope should be managed urgently and appropriately, and in patients with reflex or orthostatic syncope, it is essential to address any exacerbating medication and provide general measures to increase blood pressure.
Key Components of Inpatient Evaluation
Some key components of inpatient evaluation for syncope include:
- Detailed patient history and physical examination
- Electrocardiogram (ECG)
- Laboratory tests, including cardiac biomarkers
- Risk stratification to identify patients with life-threatening conditions
- Targeted use of additional investigations, such as cardiac imaging, provocative testing, and/or ambulatory ECG monitoring, as mentioned in 4
- Management of underlying conditions, such as cardiovascular disease, as stated in 6