From the Guidelines
For an 81-year-old female with syncope and collapse, the outpatient workup should begin with a thorough history and physical examination, focusing on cardiovascular and neurological systems, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.
Initial Evaluation
The initial evaluation should include:
- Orthostatic vital signs to assess for orthostatic hypotension
- Complete blood count, basic metabolic panel, and a 12-lead ECG to identify arrhythmias, conduction abnormalities, or ischemic changes
- A detailed history to identify the prognosis, diagnosis, reversible or ameliorable factors, comorbidities, medication use, and patient and family needs, as outlined in the 2017 ACC/AHA/HRS guideline 1
Additional Testing
Additional testing may include:
- Echocardiogram to assess cardiac structure and function, particularly for valvular disease or reduced ejection fraction
- Ambulatory cardiac monitoring (24-hour Holter or 30-day event monitor) based on the frequency of symptoms
- Carotid sinus massage if carotid hypersensitivity is suspected, but should be performed with caution in elderly patients
- Tilt-table testing for vasovagal syncope
- Carotid ultrasound if bruits are present
- Brain imaging (CT or MRI) if neurological symptoms are noted, although the ACR Appropriateness Criteria suggest that brain CT and MRI should be avoided in uncomplicated syncope 1
Medication Review
Medication review is essential as many drugs can cause orthostatic hypotension in elderly patients, including antihypertensives, diuretics, antidepressants, and alpha-blockers. Consider temporary discontinuation of potentially contributing medications.
Referral
Referral to cardiology or neurology may be necessary depending on initial findings. The comprehensive approach is important because syncope in elderly patients often has multifactorial causes and carries higher risk of serious underlying conditions like cardiac arrhythmias or structural heart disease.
From the Research
Outpatient Workup for Syncope and Collapse in an 81-Year-Old Female
Initial Evaluation
- The initial evaluation of syncope focuses on history, physical examination (including orthostatic blood pressure measurements), and electrocardiographic results 2, 3, 4.
- A thorough history and physical examination are crucial for making the diagnosis, as most patients are asymptomatic at the time of presentation 4.
- A 12-lead electrocardiogram (ECG) is the only instrumental test recommended for the initial evaluation of patients with suspected syncope 5.
Classification of Syncope
- The primary classifications of syncope are cardiac, reflex (neurogenic), and orthostatic 2, 3.
- Reflex syncope can be categorized into vasovagal syncope, situational syncope, carotid sinus syncope, and atypical reflex syncope 3.
- Cardiovascular causes of syncope may be structural (mechanical) or electrical 3.
Risk Stratification
- Patients are designated as having lower or higher risk of adverse outcomes according to history, physical examination, and electrocardiographic results 2.
- Risk stratification tools, such as the Canadian Syncope Risk Score, may be beneficial in deciding on hospital admission 2.
- Short-term risk assessment should be performed to determine the need for admission, and if the short-term risk is low, outpatient evaluation is recommended 4.
Outpatient Evaluation
- In patients with suspected cardiac syncope, monitoring is indicated until a diagnosis is made 4.
- In patients with suspected reflex syncope or orthostatic hypotension, outpatient evaluation with tilt-table testing is appropriate 4.
- Syncope units have been shown to improve the rate of diagnosis while reducing cost and are highly recommended 4.
- Laboratory tests may be ordered based on history and physical examination findings, such as 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.