From the Guidelines
The initial workup for a patient presenting with syncope should include a thorough history, physical examination, and targeted diagnostic tests, prioritizing a careful history, physical examination including orthostatic blood pressure measurements, and standard electrocardiogram (ECG) as the first steps, as recommended by the European Heart Journal in 2004 1. The initial evaluation of a patient with syncope should focus on differentiating true syncope from non-syncopal conditions associated with real or apparent transient loss of consciousness.
- A detailed account of the syncopal event, including precipitating factors, prodromal symptoms, duration, recovery period, and any associated symptoms like chest pain or palpitations, should be obtained.
- The physical examination should include orthostatic vital signs, a comprehensive cardiovascular assessment, and a neurological examination.
- An electrocardiogram (ECG) is essential for all syncope patients to evaluate for arrhythmias, conduction abnormalities, or evidence of structural heart disease, as emphasized by the American College of Cardiology in 2017 1.
- Laboratory tests should include complete blood count, basic metabolic panel, and cardiac enzymes if cardiac etiology is suspected.
- Additional first-line tests may include echocardiography for patients with abnormal cardiac examination or ECG findings, and ambulatory cardiac monitoring if arrhythmia is suspected, as suggested by the American Heart Association in 2006 1.
- Carotid sinus massage may be considered in older patients without carotid disease, and other tests such as computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in selected patients presenting with syncope of suspected cardiac etiology, as recommended by the American College of Cardiology in 2017 1. This comprehensive approach helps differentiate between cardiac, neurological, and orthostatic causes of syncope, which is crucial as cardiac syncope carries a higher mortality risk and requires prompt intervention, highlighting the importance of a thorough initial evaluation as outlined in the guidelines from the European Heart Journal in 2004 1 and the American College of Cardiology in 2017 1.
From the Research
Initial Workup for Syncope
The initial workup for a patient presenting with syncope includes:
- A detailed history to identify potential causes and risk factors 2, 3, 4, 5, 6
- Physical examination, including orthostatic blood pressure measurements to assess for orthostatic hypotension 2, 3, 4, 6
- Electrocardiographic results to evaluate for cardiac causes 2, 3, 5, 6
Risk Stratification
Risk stratification is crucial in determining the need for hospital admission and further evaluation:
- Patients with cardiac syncope are at higher risk of adverse outcomes and may require prolonged electrocardiographic monitoring, stress testing, and echocardiography 2, 3
- Patients with reflex (neurogenic) and orthostatic syncope generally have a good prognosis 2
- Risk stratification tools, such as the Canadian Syncope Risk Score, can be beneficial in informing decisions regarding hospital admission 2
Additional Testing
Additional testing may be considered if the initial findings are inconclusive and indicate possible adverse outcomes:
- Laboratory tests may be ordered based on history and physical examination findings (e.g., hemoglobin measurement if gastrointestinal bleeding is suspected) 2
- Neuroimaging should be ordered only when findings suggest a neurologic event or a head injury is suspected 2, 3
- Tilt-table testing may be appropriate for patients with suspected reflex syncope or orthostatic hypotension 4