From the Guidelines
The syncopal workup in the emergency department should focus on identifying life-threatening causes while avoiding unnecessary testing, beginning with a thorough history and physical examination, including orthostatic vital signs and a 12-lead ECG for all patients, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.
Key Components of the Workup
- A thorough history should focus on circumstances surrounding the event, prodromal symptoms, position, exertion, and associated symptoms.
- Risk stratification tools like the Canadian Syncope Risk Score can help determine which patients need admission.
- High-risk features warranting further investigation include age >60, abnormal ECG, history of heart failure or structural heart disease, exertional syncope, absence of prodrome, and associated chest pain or palpitations.
Laboratory and Additional Testing
- Laboratory testing should include complete blood count, basic metabolic panel, cardiac enzymes if cardiac etiology is suspected, and pregnancy test for women of childbearing age.
- Additional testing for selected patients may include echocardiogram, telemetry monitoring, CT head (for patients with trauma or neurological findings), carotid ultrasound (if carotid sinus hypersensitivity is suspected), and tilt-table testing for recurrent episodes.
Disposition
- Most young patients with vasovagal syncope, a normal ECG, and no concerning features can be safely discharged with outpatient follow-up, as suggested by the guideline 1.
- Hospital evaluation and treatment are recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation, according to the 2017 ACC/AHA/HRS guideline 1.
Recent Guidelines and Recommendations
- The 2021 ACR Appropriateness Criteria for syncope also emphasize the importance of a detailed history and physical examination, and recommend against routine imaging, including head CT and MRI, in patients with uncomplicated syncope 1.
- The guideline suggests that testing be limited to select patients based on clinical assessment, and that nonfocused additional testing does not improve diagnostic yield but increases hospitalization rate and cost 1.
From the Research
Syncopal Workup in the Emergency Department
- Syncopal workup is a crucial process in the emergency department, as syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12-86% of patients 2.
- A structured approach to the syncope patient in the emergency department is essential, highlighting the evidence supporting the role of clinical judgement and the initial electrocardiogram (ECG) in making the preliminary diagnosis and in safely identifying the patients at low risk of short- and long-term adverse events 2, 3.
Diagnostic Approach
- The initial ED evaluation for syncope consists of a detailed history, physical examination, and 12-lead electrocardiogram (ECG) 3, 4.
- A careful, well-conducted medical history focused on the suspected syncopal event is crucial for the diagnosis 3.
- The ECG may disclose an arrhythmia associated with a high likelihood of syncope, avoiding further evaluations and permitting institution of specific treatment in 7% of patients referred to the emergency department 3.
Risk Stratification
- Risk stratification performed in the ED is important for estimating prognosis, triage decisions, and to establish urgency of any further work-up 4.
- The primary approach to risk stratification focuses on identifying high- and low-risk predictors 4.
- The use of prediction tools may be used to aid in physician decision-making; however, they have not performed better than the clinical judgment of emergency room physicians 4.
Disposition Decisions
- Decision for hospitalization should be based on the seriousness of the underlying cause for syncope or based on high-risk features, or the severity of co-morbidities 4.
- For those deemed intermediate risk, access to specialist assessment and related testing may occur in a syncope unit in the emergency department, as an outpatient, or in a less formal care pathway and is highly dependent on the local healthcare system 4.