What is the near‑syncope evaluation template (dot phrase) for assessing patients with feeling of impending loss of consciousness?

Near-Syncope Evaluation Template (Dot Phrase)

A structured near-syncope evaluation should systematically document triggers, prodromal symptoms, witness observations, recovery characteristics, orthostatic vital signs, cardiovascular examination findings, and ECG results to differentiate benign vasovagal episodes from life-threatening cardiac causes. 1

Essential Historical Elements

Circumstances and Triggers

• Position at onset: Document if supine (high-risk for cardiac/arrhythmia), sitting (all causes possible), or standing (orthostatic hypotension, vasovagal) 1
• Activity: During exertion (cardiac structural disease, arrhythmia, LQTS1), immediately post-exercise (post-exercise hypotension in middle-aged/elderly, vasovagal in young athletes), or at rest 1
• Specific triggers: Fear/pain/instrumentation (vasovagal), micturition/defecation (situational), eating (postprandial hypotension in elderly), head turning/neck pressure (carotid sinus), coughing (situational in smokers with lung disease) 1
• Palpitations: Suggests tachyarrhythmia if present 1

Prodromal Symptoms (Onset Phase)

• Visual changes: Dark spots, loss of color vision, tunnel vision (cerebral hypoperfusion—supports syncope over seizure) 1
• Auditory changes: Sounds from distance, buzzing, ringing (cerebral hypoperfusion) 1
• Autonomic symptoms: Nausea, sweating, pallor (reflex syncope/autonomic activation) 1
• Pain pattern: Shoulder/neck "coat hanger" pain (orthostatic hypotension from muscle ischemia) 1
• Absence of prodrome: High-risk feature suggesting cardiac cause 1

Witness Account of Event

• Duration of symptoms: <30 seconds strongly favors syncope over seizure (seizures average 74-90 seconds); >5 minutes suggests psychogenic 1
• Fall pattern: Flaccid collapse (syncope), keeling over stiff (tonic seizure or less commonly syncope) 1
• Movements: Asymmetrical/asynchronous beginning after fall onset (syncope), symmetrical/synchronous beginning before fall (seizure), few movements ~10 (syncope), many movements "cannot count" (seizure) 1
• Movement timing: Beginning 20 seconds after loss of consciousness (syncope), at onset (seizure) 1

Recovery Phase

• Speed of recovery: Rapid and spontaneous (syncope), prolonged confusion (seizure) 1
• Post-event symptoms: Fatigue common in both; tongue biting, incontinence, prolonged confusion favor seizure 1

Physical Examination Requirements

Orthostatic Vital Signs (Mandatory)

• Measurement protocol: After 5 minutes supine, then each minute standing for 3 minutes minimum 1
• Orthostatic hypotension criteria: Systolic BP drop ≥20 mmHg or drop to <90 mmHg, or diastolic drop ≥10 mmHg 1
• Initial orthostatic hypotension: BP drop within 15 seconds of standing 1
• Delayed orthostatic hypotension: Takes >3 minutes to develop threshold drop 1
• Orthostatic tachycardia: Heart rate increase ≥30 bpm (≥40 bpm if age 12-19) within 10 minutes of standing, often >120 bpm, without orthostatic hypotension (suggests POTS) 1

Cardiovascular Examination

• Murmurs: Assess for aortic stenosis, hypertrophic cardiomyopathy (high-risk structural disease) 1
• Irregular rhythm: Atrial fibrillation or other arrhythmias 1
• Signs of heart failure: Elevated JVP, pulmonary crackles, peripheral edema 1

Mandatory Testing

12-Lead ECG (Required in All Cases)

• Conduction abnormalities: Sinus bradycardia <40 bpm, sinus pauses >3 seconds, Mobitz II or 3rd-degree AV block, alternating bundle branch block 1
• Arrhythmias: Paroxysmal SVT, ventricular tachycardia 1
• Ischemic changes: Acute ischemia or infarction 1
• Inherited syndromes: Long QT, Brugada pattern 1
• Pacemaker malfunction: Pauses in paced patients 1

Risk Stratification for Disposition

High-Risk Features Requiring Admission

• Age >60 years with first episode 1
• Known structural heart disease: Aortic stenosis, hypertrophic cardiomyopathy, heart failure, prior MI 1
• Abnormal ECG findings as above 1
• Syncope during exertion or while supine 1
• Absence of prodromal symptoms 1
• Family history of sudden cardiac death or inherited cardiac disease 1
• Systolic BP <90 mmHg 1
• Palpitations preceding event 1

Low-Risk Features Suggesting Outpatient Management

• Age <60 years 1
• Clear vasovagal trigger: Fear, pain, prolonged standing, hot crowded places 1
• Typical prodrome: Nausea, sweating, visual changes 1
• Normal cardiovascular examination 1
• Normal ECG 1
• No known cardiac disease 1

Tests to Avoid Without Specific Indications

• Brain imaging (CT/MRI): Diagnostic yield only 0.24-1% without focal neurological findings or head trauma 1, 2, 3, 4
• EEG: Only if seizure suspected based on witness account of movements 1, 2
• Carotid ultrasound: Only if steal syndrome suspected (arm exercise trigger, BP/pulse differential between arms) 1
• Comprehensive laboratory panels: Target testing based on clinical suspicion only (glucose if suspected hypoglycemia, hemoglobin if suspected anemia) 1, 2, 3

Additional Directed Testing (When Indicated)

For Suspected Cardiac Syncope

• Echocardiography: If structural heart disease suspected on exam or ECG 1
• Prolonged cardiac monitoring: If arrhythmia suspected but not captured on ECG 1
• Exercise stress testing: If syncope during or post-exertion 1
• Electrophysiology study: If high suspicion for arrhythmia with negative monitoring 1

For Suspected Neurally-Mediated Syncope

• Tilt-table testing: If recurrent vasovagal syncope despite non-pharmacological measures, or diagnosis uncertain 1, 2
• Carotid sinus massage: If head turning/neck pressure triggers symptoms 1

Critical Documentation Pitfalls to Avoid

• Never assume benign etiology without proper cardiac evaluation, especially with structural heart disease risk factors 2, 3, 4
• Never omit orthostatic vital signs—present in 15% of cases and changes management 1, 4
• Never discharge high-risk patients without cardiac evaluation 1
• Always document medication review for drugs causing orthostatic hypotension or arrhythmias 1, 4