What is the management plan for a patient presenting with syncope?

Management of Syncope

All patients presenting with syncope require an immediate structured evaluation consisting of detailed history, physical examination with orthostatic vital signs, and 12-lead ECG—this triad alone establishes the diagnosis in 23-50% of cases and is sufficient to guide risk stratification and disposition decisions. 1, 2

Initial Assessment Components

History Taking (Most Critical Element)

Focus on these specific elements to establish diagnosis and risk:

Circumstances of the event:

• Position during syncope: Supine/seated suggests cardiac cause; standing suggests reflex or orthostatic 1, 2
• Activity: Exertional syncope is high-risk and mandates cardiac evaluation 1, 2
• Prodrome duration: Absent or <5 seconds suggests cardiac; longer prodrome suggests vasovagal 1
• Specific triggers: Warm crowded places, prolonged standing, emotional stress, coughing, micturition, defecation suggest reflex syncope 1, 2

Witness account (essential):

• Duration of unconsciousness (brief in true syncope) 1
• Presence of tonic-clonic movements (mild brief movements can occur in any syncope; prolonged suggests seizure) 1
• Skin color changes 2
• Recovery time (rapid complete recovery without confusion confirms syncope; >30 seconds confusion suggests seizure) 1

Past medical history priorities:

• Known cardiac disease, especially ventricular arrhythmia or heart failure (strongest predictor of adverse outcome) 1
• Family history of sudden cardiac death or inherited cardiac conditions in young patients 1, 2

Medication review:

• QT-prolonging drugs, antihypertensives, vasodilators, diuretics, CNS agents 1, 2

Physical Examination

Cardiovascular examination:

• Heart rate, rhythm, murmurs (valvular disease, outflow obstruction) 1
• Signs of congestive heart failure (high risk for sudden death) 1
• Orthostatic vital signs: Measure blood pressure and heart rate lying, sitting, and standing—positive if systolic BP drops ≥20 mmHg or to <90 mmHg 1, 2

Head examination:

• Lateral tongue biting has high specificity for seizure; anterior lacerations suggest fall from syncope 1

Carotid sinus massage in patients >40 years (if no contraindications) 1, 2

12-Lead ECG (Mandatory in All Patients)

Look for these specific high-risk findings 1:

• Sinus bradycardia, sinoatrial blocks, 2nd or 3rd degree AV block
• Bifascicular block or other conduction abnormalities
• QT prolongation (>450 ms men, >460 ms women)
• Evidence of myocardial infarction
• Ventricular hypertrophy
• Pre-excitation patterns
• Brugada pattern
• Arrhythmogenic right ventricular cardiomyopathy features

Risk Stratification and Disposition

HIGH-RISK Features Requiring Hospital Admission 1, 2, 3

Admit immediately if ANY of the following:

• Age >60 years with known cardiovascular disease 1
• Abnormal ECG (any of the findings listed above) 1
• Physical exam findings of heart failure or cardiac outflow obstruction 1
• Syncope during exertion or while supine 1
• Brief or absent prodrome (<5 seconds) 1
• Low number of lifetime episodes (1-2 episodes more concerning than many) 2
• Systolic blood pressure <90 mmHg 3
• Family history of sudden cardiac death in young relatives 1
• Palpitations immediately before syncope 2

LOW-RISK Features Appropriate for Outpatient Management 1, 2, 3

Can discharge with outpatient follow-up if ALL of the following:

• Age <45 years without cardiovascular disease 1
• Normal ECG 1
• Normal cardiovascular examination 1
• Syncope only when standing 1, 2
• Clear prodromal symptoms (nausea, diaphoresis, warmth) 2
• Specific situational triggers identified 2
• No concerning family history 1

Diagnostic Testing Strategy

Tests to Order Based on Clinical Suspicion

Echocardiography (order when): 1, 2

• Structural heart disease suspected
• Abnormal cardiac examination
• Abnormal ECG suggesting structural disease
• Mandatory for syncope during or after exertion

Cardiac monitoring (select based on symptom frequency): 1

• Holter monitor (24-72 hours): For frequent symptoms
• External event recorder: For weekly symptoms
• Implantable loop recorder: For infrequent symptoms with high clinical suspicion

Exercise stress testing (order when): 2

• Mandatory for syncope during or immediately after exertion
• Chest pain suggestive of ischemia before/after syncope

Tilt-table testing (order when): 2

• Recurrent unexplained syncope in young patients without heart disease
• Suspected reflex mechanism needs confirmation

Targeted laboratory tests (order only if clinically indicated): 1

• Hemoglobin/hematocrit if acute blood loss suspected
• Pregnancy test in women of childbearing age
• Electrolytes if dehydration suspected
• Do NOT order comprehensive metabolic panels routinely 1, 2

Tests to AVOID (Low Yield, Not Recommended)

Brain imaging (CT/MRI): Diagnostic yield only 0.24-1%; order only with focal neurological findings or head trauma 2, 3

EEG: Diagnostic yield only 0.7%; order only with features suggesting seizure 2, 3

Carotid ultrasound: Diagnostic yield only 0.5%; not recommended without focal neurological findings 2, 3

Comprehensive laboratory panels: Rarely diagnostic; order only targeted tests based on clinical suspicion 1

Management by Etiology

Reflex (Neurally-Mediated) Syncope

• Patient education about triggers and prodromal symptoms 2
• Physical counterpressure maneuvers (leg crossing, hand grip, arm tensing) reduce recurrence by ~50% 3
• Increase salt and fluid intake 2
• Avoid triggers (prolonged standing, warm environments, dehydration) 2
• Discontinue or reduce vasodilators and antihypertensives 4

Orthostatic Hypotension

• Avoid rapid positional changes 2
• Increase sodium and fluid intake 2
• Review and adjust medications (especially antihypertensives, diuretics) 1, 4
• Consider fludrocortisone or midodrine in severe cases 5

Cardiac Syncope

• Requires cardiology consultation 2
• Arrhythmias may require pacemaker or ICD placement 6
• Structural disease may require surgical correction 6

Special Populations

Geriatric Patients (>75 years)

• Multidisciplinary approach with geriatric consultation is beneficial 1
• Syncope often multifactorial (polypharmacy, frailty, multiple comorbidities) 1
• Consider syncope as cause of "falls"—30% of nonaccidental falls in elderly are actually syncope 1
• Amnesia and cognitive impairment reduce accuracy of history 1
• Higher risk of physical injury and loss of independence 1

Critical Pitfalls to Avoid

• Do NOT assume syncope at rest is benign—this is a high-risk feature requiring cardiac evaluation 3
• Do NOT order brain imaging, EEG, or carotid ultrasound routinely—yield is <1% without specific indications 2, 3
• Do NOT order comprehensive laboratory panels—order only targeted tests based on clinical suspicion 1
• Do NOT overlook medication effects—review all medications for QT prolongation, hypotension, or drug interactions 1, 2
• Do NOT use Holter monitoring indiscriminately—select monitoring duration based on symptom frequency 1
• Do NOT discharge high-risk patients—even one high-risk feature warrants admission 1

Driving Restrictions

• Patients with untreated syncope should not drive 4
• After treatment, observe symptom-free period of 1 month before resuming driving 4
• Risk assessment considers likelihood of recurrence and warning symptoms 1