From the Guidelines
This patient's presentation is most consistent with benign positional syncope, and therefore, no further cardiac-specific testing or treatment is immediately warranted beyond a basic cardiovascular assessment to rule out underlying cardiac disease. The patient experienced syncope during hair washing with her head tilted back, which is consistent with a vasovagal episode triggered by carotid sinus stimulation in this position 1. The initial troponin elevation of 50 ng/L followed by a rapid decrease to 4 ng/L within 2 hours suggests this was not an acute coronary syndrome, as a true cardiac event would typically show rising troponin levels 1.
Key points to consider in the management of this patient include:
- Avoiding prolonged neck hyperextension, especially in elderly patients, to prevent future episodes of syncope.
- Advising the patient to request modified positioning during future hair washing, such as leaning forward over a sink rather than backward.
- Rising slowly from supine positions to prevent orthostatic hypotension.
- A basic cardiovascular assessment is reasonable but should be guided by the clinical suspicion of underlying cardiac disease, as routine and comprehensive laboratory testing is not useful in the evaluation of patients with syncope unless directed by clinical suspicion 1.
The use of biomarkers such as troponin and natriuretic peptides may have limited value in this context unless there is a high suspicion of cardiac cause for the syncope, and even then, their ability to influence clinical decision making or patient outcome is unknown 1. Therefore, management should focus on preventive measures and addressing any underlying conditions that may predispose to syncope, rather than relying heavily on biomarker testing.
From the Research
Evaluation of Syncope
The patient's brief syncopal episode after having their head leaned back in the sink while getting their hair washed, with initial Troponin I (Trop I) 50ng/L and repeat in 2 hrs was 4 ng/L, suggests a possible diagnosis of syncope. According to 2, syncope is an abrupt, transient, and complete loss of consciousness associated with an inability to maintain postural tone, with rapid and spontaneous recovery.
Classification of Syncope
The primary classifications of syncope are:
- Cardiac syncope
- Reflex (neurogenic) syncope
- Orthostatic syncope As stated in 3, neurally mediated syncope is the most common type and has a benign course, whereas cardiac syncope is associated with increased morbidity and mortality.
Diagnostic Approach
The initial assessment for all patients presenting with syncope includes:
- A detailed history
- Physical examination
- Electrocardiography (ECG) As mentioned in 4, a 12-lead ECG is the only instrumental test recommended for the initial evaluation of patients with suspected syncope.
Risk Stratification
Patients are designated as having lower or higher risk of adverse outcomes according to history, physical examination, and electrocardiographic results, which can inform decisions regarding hospital admission. Risk stratification tools, such as the Canadian Syncope Risk Score, may be beneficial in this decision, as stated in 2.
Laboratory Tests and Neuroimaging
Laboratory tests, such as troponin levels, may be ordered based on history and physical examination findings. Neuroimaging should be ordered only when findings suggest a neurologic event or a head injury is suspected, as mentioned in 2 and 3.
Management
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, as stated in 3 and 5. Mechanism-specific therapy, such as counteracting hypotension or bradycardia, can be effective in preventing recurrences, as mentioned in 5.