From the Guidelines
The standard work-up for syncope in a 60-year-old patient with no ongoing symptoms should include a thorough history, physical examination, and targeted diagnostic testing, prioritizing the identification of cardiac causes due to their high risk of mortality, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. The evaluation should begin with a 12-lead ECG to evaluate for arrhythmias, conduction abnormalities, or ischemic changes.
- Obtain orthostatic vital signs by measuring blood pressure and heart rate while lying, sitting, and standing to assess for orthostatic hypotension.
- Basic laboratory tests should include complete blood count, basic metabolic panel, cardiac enzymes (troponin), and blood glucose.
- Consider an echocardiogram to evaluate cardiac structure and function, particularly if there is concern for structural heart disease, as certain conditions such as aortic stenosis or hypertrophic cardiomyopathy can cause syncope due to mechanical obstruction or neural reflex mechanisms 1.
- A Holter monitor or event recorder may be appropriate for outpatient monitoring if arrhythmia is suspected but not captured on initial ECG.
- Carotid sinus massage might be performed in controlled settings if carotid sinus hypersensitivity is suspected.
- Tilt-table testing could be considered for recurrent episodes with suspected vasovagal etiology.
- Neuroimaging (CT or MRI) is generally not indicated in the absence of neurological symptoms or signs, as studies have shown a low yield of acute abnormalities on head CT in patients with syncope or presyncope without external evidence of head trauma or focal neurological deficit 1. The focus of the evaluation should be on identifying cardiac causes of syncope, as these carry the highest risk of mortality, particularly in older adults, with certain patient characteristics such as age >60 years, male gender, and known underlying cardiac disease increasing the risk of cardiac-related syncope 1.
- Medication review is essential, as many drugs can contribute to syncope through effects on blood pressure, heart rate, or QT interval.
From the Research
Standard Work-up for Syncope
The standard work-up for syncope in a 60-year-old patient with stable vitals, no neurological deficits, and no signs of infection, who has returned to normal after being found slumped over in a chair, involves a thorough initial evaluation, including:
- Clinical history-taking, which remains the most important aspect of the clinical assessment 2
- Physical examination
- 12-lead ECG, which can help identify cardiac causes of syncope 3, 2
- Neuroautonomic assessment, such as tilt testing and carotid sinus massage, which can help diagnose neurally mediated syncope 4
Diagnostic Approach
The diagnostic approach to syncope should be structured and based on the underlying pathophysiological mechanism causing the event, including:
- Cardiac causes, such as arrhythmias or structural heart disease 3, 2
- Orthostatic hypotension, which can be caused by autonomic nervous system failure or hypovolaemia 2
- Reflex syncope, which can be categorised into vasovagal syncope, situational syncope, carotid sinus syncope, and atypical reflex syncope 2
Investigation and Management
Investigation and management of syncope should be guided by the initial evaluation and may include:
- ECG monitoring, which can help diagnose arrhythmias or other cardiac causes of syncope 3, 5
- Echocardiogram, which can help evaluate cardiac structure and function 3
- Stress test, which can help evaluate cardiac function and identify potential cardiac causes of syncope 3
- Referral to a cardiologist for further evaluation and management, if a cardiac cause is suspected 2, 6
- Implementation of functional and multidisciplinary Syncope Units, which can help reduce inappropriate tests and hospitalization rates 4