From the Guidelines
The workup of syncope and collapse in a 72-year-old female should begin with a detailed history and physical examination, as recommended by the 2017 ACC/AHA/HRS guideline 1. This initial assessment is crucial for identifying the prognosis, diagnosis, reversible or ameliorable factors, comorbidities, medication use, and patient and family needs. The history should aim to identify the situations in which syncope occurs, prodromal symptoms, patient’s self-report, bystander observations of the event and vital signs, and post-event symptoms, with particular emphasis on differentiating between neurally mediated and cardiac syncope 1. Key aspects of the history include:
- Circumstances surrounding the event
- Prodromal symptoms
- Position at onset
- Duration
- Post-event symptoms
- Medication review The physical examination should include:
- Determination of orthostatic blood pressure and heart rate changes
- Careful attention to heart rate and rhythm
- Assessment for murmurs, gallops, or rubs indicating structural heart disease
- A basic neurological examination to identify focal defects or abnormalities suggesting further neurological evaluation 1. Given the high risk of cardiac syncope in elderly patients, which carries a significantly worse prognosis than neurally mediated syncope, a thorough cardiovascular assessment is essential 1. Initial testing should be guided by the findings from the history and physical examination, with a focus on assessing for arrhythmias, conduction abnormalities, or ischemic changes. Further specialized testing, such as ambulatory cardiac monitoring, echocardiography, or implantable loop recorders, may be warranted based on the initial evaluation and suspected causes of syncope. Management should be tailored to the identified cause, prioritizing interventions that improve morbidity, mortality, and quality of life, such as medication adjustments, pacemaker implantation, or lifestyle modifications.
From the Research
Initial Evaluation
The workup of syncope and collapse in a 72-year-old female should begin with a thorough history and physical examination, including orthostatic assessment 2, 3, 4, 5. This initial evaluation is crucial in determining the cause of syncope and guiding further management.
Classification of Syncope
Syncope can be classified into several categories, including:
- Cardiac syncope, which is associated with higher rates of morbidity and mortality 3, 5
- Reflex (neurogenic) syncope, which can be further categorized into vasovagal syncope, situational syncope, carotid sinus syncope, and atypical reflex syncope 2
- Orthostatic syncope, which is caused by an abnormal drop in systolic blood pressure upon standing 2, 5
Diagnostic Tests
The following diagnostic tests may be considered in the evaluation of syncope:
- Electrocardiography (ECG), which is the only instrumental test recommended for the initial evaluation of syncope 6
- Prolonged electrocardiographic monitoring, stress testing, and echocardiography, which may be beneficial in patients at higher risk of adverse outcomes from cardiac syncope 3, 5
- Head-up tilt-table testing and carotid sinus massage, which can be used to diagnose neurogenic reflex-mediated syncope 3
- Neuroimaging, which should be ordered only when findings suggest a neurologic event or a head injury is suspected 3, 5
Risk Stratification
Risk stratification tools, such as the Canadian Syncope Risk Score, can be used to determine the risk of adverse outcomes and inform decisions regarding hospital admission 5. Patients with cardiac syncope are at higher risk of adverse outcomes, while those with reflex and orthostatic syncope have a better prognosis 5.
Management
The management of syncope depends on the underlying cause and may involve:
- Addressing exacerbating medications and providing general measures to increase blood pressure, such as physical counter-pressure maneuvers, in patients with reflex or orthostatic syncope 2
- Referral to a cardiologist for further evaluation and management in patients with cardiac syncope 2, 3
- Implementation of mechanism-specific and effective therapeutic strategies to prolong survival, limit physical injuries, and prevent recurrences 2