What is the management approach for syncope?

Management of Syncope

The management of syncope requires a structured diagnostic approach based on initial evaluation to identify the underlying cause, followed by targeted treatment of the specific etiology to reduce morbidity, mortality, and recurrent episodes. 1

Initial Evaluation and Risk Stratification

History and Physical Examination

• Position and activity at onset (supine, sitting, standing, during/after exercise)
• Precipitating factors: crowded places, prolonged standing, post-prandial, fear, pain, neck movements
• Prodromal symptoms: nausea, sweating, blurred vision, abdominal discomfort
• Eyewitness account: manner of falling, skin color, duration of unconsciousness, breathing pattern, movements
• Post-event symptoms: confusion, nausea, sweating, muscle aches, injury, chest pain
• Background: family history of sudden death, cardiac disease, neurological disorders, medications

Immediate Assessment

1. 12-lead ECG in all patients
2. Basic laboratory tests only if suspecting volume depletion or metabolic causes 1
3. Orthostatic vital signs if orthostatic hypotension suspected

Management Algorithm Based on Initial Evaluation

1. Certain/Suspected Diagnosis After Initial Evaluation

• Implement specific treatment for the identified cause
• Hospital admission required for patients with serious medical conditions identified during evaluation 1

2. Unexplained Syncope - Management Based on Risk

High Risk (Presence of structural heart disease or abnormal ECG)

• Hospital-based evaluation 1
• Cardiac evaluation sequence:
  1. Echocardiography
  2. Prolonged ECG monitoring
  3. Electrophysiological studies if non-diagnostic 1

Intermediate Risk

• Structured ED observation protocol with time-limited observation and expedited cardiac testing/consultation 1
• Consider outpatient management with expedited specialist referral

Low Risk (No structural heart disease and normal ECG)

• Outpatient management for presumptive reflex-mediated syncope 1
• For recurrent/severe syncope:
  • Young patients: Tilt testing
  • Older patients: Carotid sinus massage 1
• Close follow-up for patients with single/rare episodes 1

Specific Management Based on Etiology

Neurally Mediated (Vasovagal) Syncope

1. Education and reassurance about benign prognosis 1
2. Trigger avoidance when feasible
3. Non-pharmacological measures:
   • Increased salt and fluid intake (2-2.5L/day)
   • Physical counterpressure maneuvers (leg crossing, squatting)
   • Abdominal binders or compression stockings
   • Head-up tilt sleeping (>10°)
   • Regular exercise, especially swimming 1, 2
4. Pharmacological therapy for refractory cases (limited evidence for efficacy)
5. Cardiac pacing only for:
   • Cardioinhibitory or mixed carotid sinus syndrome
   • Cardioinhibitory vasovagal syncope with >5 attacks per year or severe injury and age >40 1

Orthostatic Hypotension

1. Eliminate offending medications (diuretics, vasodilators)
2. Volume expansion through increased salt/fluid intake
3. Fludrocortisone in low doses (0.1-0.2mg daily)
4. Physical countermeasures and compression garments 1

Cardiac Syncope

1. Arrhythmic causes: Pacemaker/ICD placement or medication modification
2. Structural causes: Treatment of underlying condition (e.g., aortic stenosis)
3. Ischemic causes: Standard management of coronary artery disease 1

Special Considerations

When to Hospitalize

• Presence of serious medical conditions requiring immediate treatment
• Suspected cardiac syncope with high risk features
• Injury resulting from syncope
• Frequent recurrent episodes 1

When Further Investigation is Needed

• Implantable loop recorder indicated when:
  • Mechanism remains unclear after full evaluation
  • Clinical/ECG features suggest arrhythmic syncope
  • History of recurrent syncopes with injury 1

Reappraisal of Unexplained Syncope

• Review entire workup and obtain additional history details
• Consider psychiatric assessment for patients with frequent recurrent syncope and multiple somatic complaints 1

Pitfalls and Caveats

• Beta-blockers are not recommended for vasovagal syncope and may worsen bradycardia in cardioinhibitory cases 1
• Avoid nocturnal hypertension when treating orthostatic hypotension
• Cardiac syncope carries the worst prognosis (20-30% one-year mortality) and requires aggressive evaluation and treatment 3
• Failure to identify genetic cardiac conditions (Long-QT syndrome, Brugada syndrome) can lead to preventable sudden cardiac death 4
• Overuse of diagnostic tests increases healthcare costs without improving outcomes 4, 5

By following this structured approach to syncope management, clinicians can effectively identify underlying causes, implement appropriate treatments, and reduce the risk of recurrence and adverse outcomes.