Clinical Scholars Rcvicw, \olumc 2, Numbcr 2, 2009 Springcr Publishing Company 65

!: 10.1891/19392095.2.2.65
LITERATURE REVIEW

Syncopc is a transicnt loss ol consciousncss (TLC) prc

cipitatcd by ccrcbral hypopcrlusion, which is associatcd
with thc abscncc ol postural tonc and usually lollowcd
by a complctc rccovcry within a lcw minutcs (8rignolc
ct al., 2004, Sotcriadcs ct al., 2002). Tis clinical condi
tion is a common mcdical problcm with an cstimatcd in
cidcncc ol 6.2 pcr 1,000 pcrsonycars and accounts lor
1 ol cmcrgcncy dcpartmcnt () visits and 6 ol all
hospital admissions (Grossman ct al., 2007, Sotcriadcs
ct al., 2002). Syncopc may bc duc to a multitudc ol dis
casc proccsscs, and thc ctiology ol syncopc may rcmain
unknown in a largc pcrccntagc ol paticnts (8rignolc ct al.
2004, iscrtori ct al., 2003). stablishing thc diagnosis
ol syncopc is important so that spccic trcatmcnt can bc
institutcd to prcvcnt luturc rccurrcnccs and climinatc thc
undcrlying prcdisposing discasc (Ammirati, Colivicchi, &
Santini, 2000, 8rignolc & Shcn, 2008, Sotcriadcs ct al.,
2002). 8ccausc ol thc sporadic and inlrcqucnt naturc ol
syncopal cvcnts in a givcn paticnt, cstablishing a corrcct
diagnosis rcmains thc major challcngc in managing thcsc
paticnts (8rignolc ct al., 2004, Kapoor, 2002, Strickbcrgcr
ct al., 2006).
Evaluation and Management
of Syncope
Joannc L. Thanavaro, NP, ANP8C,
ACNP8C, CC
St. Louis University School of Nursing, Missouri
Syncopc is a transicnt loss ol consciousncss prccipitatcd by ccrcbral hypopcrlusion, which is associatcd
with a bricl abscncc ol postural tonc and usually lollowcd by a complctc rccovcry. Tis clinical condition
is a common mcdical problcm and may bc attributcd to a multitudc ol discasc proccsscs. Risk stratica
tion idcntics thc salcst sctting lor thc initial cvaluation as wcll as which paticnts arc most likcly to havc
a lilcthrcatcning cvcnt. stablishing thc diagnosis ol syncopc is important so that spccic trcatmcnt
can bc institutcd to prcvcnt luturc rccurrcnccs and climinatc thc undcrlying prcdisposing discasc. Tis
articlc rcvicws thc ctiology, risk stratication, diagnosis, and thcrapcutic managcmcnt ol syncopc.
Keywords: syncopc, ccrcbral hypopcrlusion, cardiac syncopc, risk stratication, syncopc cvaluation,
driving guidclincs
Syncope Evaluation
Tc initial considcration in cvaluating syncopc is to dil
lcrcntiatc truc syncopc lrom nonsyncopal cvcnts such as
psychogcnic pscudosyncopc, scizurcs, mctabolic disordcrs
(hypoxia or hypoglyccmia), and intoxications (8rignolc
ct al., 2004, Kapoor, 2002). !n psychogcnic pscudosyn
copc, thc paticnt has undcrlying psychogcnic lactors and
manilcsts symptoms ol convcrsion rcaction with transicnt
abnormal rcsponsc without loss ol consciousncss. Tc di
agnosis should bc considcrcd il thc paticnt prcscnts with a
prolongcd abnormal rcsponsc (1030 minutcs), lrcqucnt
cpisodcs (up to scvcral timcs a day), and lack ol physi
cal injury (Vicling, Ganzcboom, & Saul, 2004). Scizurcs,
mctabolic disordcrs, and intoxications may causc TLC
but not on thc basis ol ccrcbral hypopcrlusion, scizurc
disordcrs arc thc most common nonsyncopal TLC
(Strickbcrgcr ct al., 2006). Tcrc arc two main rcasons to
cvaluatc paticnts with syncopc: to dctcrminc thc ctiol
ogy ol syncopc and to stratily thc risk ol luturc advcrsc
outcomcs (Figurc 1) (8rignolc ct al., 2004, Colivicchi
ct al., 2003, Costantino ct al., 2008, iscrtori ct al., 2003,
Quinn, Mccrmott, Sticll, Kohn, & Vclls, 2004, Sun
66 Thanavaro
Figure 1. Syncopc cvaluation.
ct al., 2007). Tc rcsult ol this initial cvaluation will dctcr
minc lurthcr diagnostic or thcrapcutic stratcgics and thc
nccd lor hospital admission or outpaticnt tcsting (8rignolc
ct al., 2004, Hu ct al., 2007).
Etiology of Syncope
According to thc uropcan Socicty ol Cardiology (SC),
syncopc may bc classicd into vc major catcgorics: ncu
rally mcdiatcd, orthostatic, cardiac arrhythmia rclatcd,
structural hcart discasc rclatcd, and ccrcbrovascular
syncopc (Tablc 1) (8rignolc ct al., 2004).
Neurally Mediated (Reflex) Syncope
Ncurally mcdiatcd syncopc (NMS) is causcd by a rccx
rcsponsc with vasodilatation and bradycardia contributing
to systcmic hypotcnsion and/or ccrcbral hypopcrlusion.
Tc classical vasovagal syncopc, carotid sinus syncopc, and
situational syncopc arc includcd in this catcgory. \asova
gal syncopc is prccipitatcd by cmotions, unplcasant sights
or sounds, pain, or orthostatic strcss (prolongcd standing
in crowdcd or hot placcs) and is typically associatcd with
postcpisodc latiguc, wcakncss, nausca, or vomiting (Alboni
ct al., 2001, 8rignolc ct al., 2004, Strickbcrgcr ct al., 2006).
Carotid sinus syncopc is rclatcd to accidcntal mcchanical
manipulation ol thc carotid sinuscs, such as ncck turning,
shaving, or tight collars (Kapoor, 2002, Strickbcrgcr ct al.,
2006). Situational syncopc rclcrs to thosc lorms ol NMS
associatcd with spccic sccnarios, such as micturition,
coughing, or dclccating.
Orthostatic Syncope
rthostatic syncopc rclcrs to syncopc in which thc
upright position causcs hypotcnsion and ccrcbral hypop
crlusion without bradycardia (8rady & avis, 2003,
8rignolc ct al., 2004). Tis typc ol syncopc usually occurs
altcr standing up, with cxcrtion or associatcd with pro
longcd standing in crowdcd or hot placcs. rthostatic
hypotcnsion occurs whcn thc autonomic ncrvous systcm
rcsponsc to changcs in position is laulty or il thc paticnt
is hypovolcmic. Scvcral causcs ol orthostatic hypotcnsion
includc mcdications, ncurogcnic causcs such as mul
tisystcm atrophy (MSA), Parkinsonism and diabctic
ncuropathy, and nonncurogcnic causcs such as impaircd
vcnous rcturn, hypovolcmia, and cardiac insu cicncy
(8rady & avis, 2003, 8rignolc ct al., 2004). MSA is a
sporadic ncurodcgcncrativc disordcr charactcrizcd by
a combination ol Parkinsonian, autonomic, ccrcbcllar,
or pyramidal signs and symptoms and may prcscnt with
orthostatic hypotcnsion as a rcsult ol autonomic lailurc
(Colosimo, Tiplc, & Vcnning, 2005).
Evaluation and Management of Syncope 67
and cardiomyopathy arc othcr structural hcart discascs
that may causc syncopc by prcdisposing paticnts to
paroxysmal \T.
Cerebrovascular Syncope
Ccrcbrovascular syncopc is also rclcrrcd to as ncurological
syncopc and occurs as a rcsult ol dccrcascd ccrcbral pcr
lusion associatcd with ccrcbrovascular discasc. Tc stcal
syndromc occurs in subclavian obstruction whcn prclcr
cntial blood ow is divcrtcd lrom thc brain to thc arm
during arm activity (8rignolc ct al., 2004). Paticnts with
scvcrc vcrtcbrobasilar or bilatcral carotid artcry discasc
may cxpcricncc syncopc associatcd with local ncurologi
cal symptoms (Strickbcrgcr ct al., 2006). Tc physical
cxamination in thcsc paticnts may rcvcal carotid bruits
or wcak or abscnt brachial or radial pulscs. Vhilc uncom
mon (1), this typc ol syncopc should bc cntcrtaincd as a
possiblc causc il suggcstcd by history or physical ndings
(Alboni ct al., 2001, Strickbcrgcr ct al., 2006).
Risk Stratification of Syncope
Short-Term Risk (Table 2)
Tcrc arc only a lcw studics that dircctly cvaluatc thc
short and longtcrm risk ol syncopc (Colivicchi ct al.,
2003, iscrtori ct al., 2003, Quinn ct al., 2004, Sun ct al.,
2007). Tc San Francisco syncopc rulc (SFSR) may ocr
somc guidancc in prcdicting which paticnts arc likcly to
havc shorttcrm (7day) scrious outcomcs and to guidc
hospital admission dccisions (Quinn ct al., 2004). Tc
initial dcrivation study cnrollcd 684 paticnts with syn
copc and ncar syncopc (Quinn ct al., 2004). Paticnts with
syncopc arc at 25 risk lor scrious outcomcs il thcy prcs
cnt with onc ol thcsc vc clinical conditions: congcstivc
hcart lailurc (CHF), hcmatocrit 30, clcctrocardiogram
(CG) abnormalitics (nonsinus rhythm or ncw changcs),
shortncss ol brcath, or systolic blood prcssurc 90 mm Hg.
Tc CHSS acronym may assist in rcmcmbcring thcsc
conditions. Scrious outcomcs includc dcath, myocardial
inlarction, cardiac arrhythmias, pulmonary cmbolism,
strokc, subarchnoid hcmorrhagc, signicant hcmorrhagc,
rcvisit, or hospital admission. Quinn ct al. (2004) and
Quinn, Mccrmott, Sticll, Kohn, and Vclls (2006) rc
portcd a high scnsitivity (96 and 98) and modcratc
spccicity (62 and 56) ol SFSR in both initial dcri
vation and validation studics. Howcvcr, an indcpcndcnt
validation ol thc SFSR dcmonstratcd a lowcr scnsitivity
(89) and spccicity (42), suggcsting that thc rulc has
limitcd gcncralizability (Sun ct al., 2007).
Cardiac ArrhythmiaRelated Syncope
Cardiac arrhythmias may prccipitatc syncopc bccausc
bradycardia or tachycardia causcs a dccrcasc in cardiac
output rcgardlcss ol circulatory dcmands (8rignolc ct al.,
2004). Tc potcntial causcs ol syncopc in this catcgory arc
sinus nodc dyslunction, atriovcntricular (A\) conduction
abnormalitics, paroxysmal supravcntricular (S\T) and
vcntricular tachycardias (\T), VolParkinsonVhitc
(VPV) syndromc, and inhcritcd syndromcs, such
as long QT syndromc (LQTS) or 8rugada syndromc
(8rignolc ct al., 2004, Strickbcrgcr ct al., 2006).
Structural Heart DiseaseRelated Syncope
Structural hcart discascs (SH) such as aortic stcnosis,
obstructivc cardiomyopathy, pulmonary hypcrtcnsion,
or atrial myxomas can prccipitatc syncopc bccausc cir
culatory dcmands outwcigh thc impaircd ability ol thc
hcart to incrcasc cardiac output (8rignolc ct al., 2004,
Strickbcrgcr ct al., 2006). Pulmonary cmbolism is also in
cludcd in this catcgory. Coronary artcry discasc (CA)
TABLE . Classication and tiology ol Syncopc
1. Ncurally mcdiatcd (rccx) syncopc
\asovagal syncopc
Carotid sinus syncopc
Situational syncopc
2. rthostatic syncopc
Autonomic lailurc
ruginduccd orthostatic hypotcnsion
\olumc dcplction
3. Cardiac arrhythmiarclatcd syncopc
Sinus nodc dyslunction (bradycardia/tachycardia syndromc)
Atriovcntricular conduction systcm discasc
Paroxysmal supravcntricular and vcntricular tachycardias
VolParkinsonVhitc syndromc
!nhcritcd syndromcs (Long QT syndromc, 8rugada syndromc)
ruginduccd proarrhythmias
4. Structural hcart discascrclatcd syncopc
bstructivc cardiac valvular discasc
Cardiomyopathy
Atrial myxoma
Coronary artcry discasc
5. Ccrcbrovascular syncopc
\ascular stcal syndromcs
\crtcbrobasilar artcry discasc
Carotid artcry discasc
68 Thanavaro
TABLE . ShortTcrm Risk Stratication ol Syncopc
San Francisco Syncopc Rulc (SFSR):
a

Prcdictors ol shorttcrm outcomcs (7day):
CHSS
Congcstivc hcart lailurc
Hcmatocrit 30
CG abnormalitics
Shortncss ol brcath
Systolic blood prcssurc 90 mm Hg
8oston Syncopc Critcria (8SC):
b

Prcdictors ol shorttcrm outcomcs (30day)
History ol ACS
Suspicious cardiac history
Abnormal cardiac cxamination
vidcncc ol conduction discasc)
Family history ol SC
Pcrsistcnt abnormal vital signs
\olumc dcplction (pcrsistcnt dchydration,
gastrointcstinal blccding or
hcmatocrit 30)
ShortTcrm Prognosis ol Syncopc (STcPS):
c

Prcdictors ol shorttcrm outcomcs (10day) by
multivariant analysis
Abnormal CG
Concomitant trauma
Abscncc ol prodromal symptoms
Malc gcndcr
utcomcs (25 ovcrall incidcncc with
at lcast onc risk lactor)
cath
Myocardial inlarction
Arrhythmia
Pulmonary cmbolism
Strokc
Subarchnoid hcmorrhagc
Signicant hcmorrhagc
Rcadmission to cmcrgcncy dcpartmcnt
or hospital admission
Primary outcomcs (23 ovcrall incidcncc)
!ntcrvcntion:
Antiarrhythmic trcatmcnt
Paccmakcr/!C placcmcnt
Myocardial rcvascularization
Cardiopulmonary rcsuscitation (CPR)
8lood translusion
ndoscopy with intcrvcntion
Corrcction ol carotid stcnosis
utcomcs:
cath
Myocardial inlarction
Arrhythmia
Pulmonary cmbolism
Strokc
Subarchnoid hcmorrhagc
Signicant hcmorrhagc
Cardiac arrcst
!nlcction/scpsis
Lilcthrcatcning scquclac (rhabomyolysis,
long bonc or ccrvical spinc lracturcs)
utcomcs (6.1 ovcrall incidcncc)
cath (0.7)
Major thcrapcutic proccdurcs (5.4) (CPR,
paccmakcr or !C inscrtion, !CU
admission)
arly hospital rcadmission
a
Quinn ct al. (2004).
b
Grossman ct al. (2007).
c
Costantino ct al. (2008).
Tc 8oston Syncopc Critcria (8SC) is a clinical strat
cgy, which was dcvclopcd to dctcrminc thc prognosis ol
syncopc bascd on thc SFSR and thc Amcrican Collcgc
ol mcrgcncy Physicians (ACP) clinical policy (is
crtori ct al., 2001, Hu ct al., 2007, Quinn ct al., 2004).
Tc 8SC consists ol cight catcgorics that could acct
primary outcomcs ovcr 10 days, consisting ol a critical
intcrvcntion or an advcrsc outcomc. Tc incidcncc ol
primary outcomcs in thc original study ol 184 paticnts
was 21, and thc 8SC dcmonstratcd 97 scnsitivity and
62 spccicity in idcntilying thcsc paticnts (iscrtori
ct al., 2001). Clinical application ol thc 8SC lcd to a 48
rcduction in hospital admissions.
Tc ShortTcrm Prognosis ol Syncopc (STcPS) study
asscsscd scvcrc outcomcs ol syncopc in 676 paticnts, in
cluding dcath, major thcrapcutic proccdurcs, and carly
hospital rcadmission (Costantino ct al., 2008). Tc major
thcrapcutic proccdurcs wcrc dcncd as cardiopulmonary
arrcst, paccmakcr or implantablc cardiovcrtcr dcbrillator
(!C) inscrtion, and intcnsivc carc unit admission. Tc
ovcrall incidcncc ol scvcrc shorttcrm (!0day) outcomcs
was 6.!, including 0.7 lor mortality and .4 lor major
thcrapcutic proccdurcs. Tc multivariant analysis idcnti
cd abnormal CGs, concomitant trauma, abscncc
ol symptoms ol impcnding syncopc, and malc gcndcr
as prcdictors ol shorttcrm risk lor scrious outcomcs
(Costantino ct al., 2008).
Long-Term Risk (Table 3)
Martin, Hanusa, and Kapoor (1997) dcvclopcd a long
tcrm risk stratication systcm lor cardiac arrhythmia and
1ycar mortality, including abnormal CG, a history ol
vcntricular arrhythmia or CHF, and agc ~5 ycars. vcnts
rangcd lrom 0 lor thosc without risk lactors to 27 lor
thosc with thrcc or lour risk lactors. Tc S!L (sscr
vatorio pidcmiologico dclla Sincopc ncl Lazio) rcportcd
agc ~5 ycars, lack ol prodromcs, history ol cardiovascular
Evaluation and Management of Syncope 69
risk lor cardiac syncopc and should bc thc primary locus
ol thc initial syncopc cvaluation (Alboni ct al., 200!, Chcn
ct al., 2000).
Hospital Admission
Paticnt disposition altcr thc initial cvaluation is an im
portant aspcct ol thc managcmcnt ol syncopc. Currcntly,
thcrc arc two guidclincs that can hclp with dccisions in
rcgard to hospital admission (8rignolc ct al., 2004, Hu
ct al., 2007). Tc ACP dcvclopcd a policy lor hospital
admission bascd on risk stratication (Hu ct al., 2007).
Paticnts with oldcr agc and comorbiditics, an abnormal
CG, Hct 0, and history or prcscncc ol CHF, ischcmia,
or othcr SH arc at high risk ol having advcrsc outcomcs
and should bc admittcd to thc hospital. Tc SC providcs
anothcr guidclinc that is bascd on thc nccd lor diagnostic
or thcrapcutic intcrvcntions (8rignolc ct al., 2004). Hos
pital admission lor diagnostic cvaluation is rccommcndcd
lor paticnts with suspcctcd or known signicant SH,
an abnormal CG suggcstivc ol arrhythmic syncopc, syn
copc occurring during cxcrcisc or supinc position, syncopc
causing scvcrc injury (skull or bonc lracturcs, intracranial
hcmorrhagc or intcrnal organ injurics), lamily history ol
SC, or suspcctcd dcvicc mallunction (8rignolc ct al.,
2004). Tcrapcutic indications lor admission according
to thc SC includc syncopc duc to cardiac arrhythmias,
ischcmia, SH, or cardiopulmonary discasc or ncurally
mcdiatcd bradycardia rcquiring paccmakcr implantation
(8rignolc ct al., 2004).
Syncopc managcmcnt units (SMUs) wcrc rcccntly
dcvclopcd to improvc paticnt carc (8rignolc ct al., 2004,
8rignolc, Ungar, ct al., 2006, Shcn ct al., 2004). Tis
multidisciplinary unit is cquippcd with cardiac monitoring
and paticnts havc immcdiatc acccss to cchocardiogram,
discasc, and abnormal CGs as prcdictors ol 1ycar mor
tality (0, 0.8, 19.6, 34.7, and 57.1 incidcncc lor
zcro, onc, two, thrcc, and lour risk lactors, rcspcctivcly)
(Colivicchi ct al., 2008). STcPS also asscsscd longtcrm
(1ycar) scrious outcomcs (ovcrall incidcncc ol 9.3) ol
syncopc and lound agc ~5 ycars, vcntricular arrhythmias,
SH, ccrcbrovascular discasc, and ncoplasm to bc prc
dictors ol 1ycar mortality (6.0) and major thcrapcutic
proccdurcs (3.3) (Costantino ct al., 2008).
Tcrc is no optimal risk stratication to datc, and thc
discrcpancics in prior studics makc it di cult to comparc
thcir clinical applicapability. Tc 8SC, which includcd morc
clinical prcdictors and advcrsc outcomcs, rcportcd a similar
scnsitivity and spccicity to thc initial study ol SFSR, but
its rcsults havc not bccn validatcd (iscrtori ct al., 2001).
A lowcr spccicity and scnsitivity lor thc SFSR in onc in
dcpcndcnt validation and a low positivc prcdictivc valuc ol
thc STcPS indicatc thc nccd lor additional studics bclorc
thcy can bc rccommcndcd as a standard ol carc lor as
scssing thc paticnt with syncopc (8rignolc & Shcn, 2008,
Costantino ct al., 2008, Sun ct al., 2007).
Tc risk ol dcath and othcr advcrsc outcomcs ol syn
copc appcars to bc rclatcd to thc undcrlying discasc or
paticnts gcncral risks rathcr than thc syncopc itscll (8ri
gnolc & Shcn, 2008, Colivicchi ct al., 2001, Costantino
ct al., 2008, Martin ct al., !997). Paticnts with cardiac syn
copc havc highcr ratcs ol suddcn cardiac dcath (SC)
and allcausc mortality than thosc without a cardiac causc
(Sotcriadcs ct al., 2002, Strickbcrgcr ct al., 2006). Tc
ycar mortality ratc in paticnts with cardiac syncopc has
bccn rcportcd to approach 0, with a 10 incidcncc ol
dcath in thc rst ycar (Sotcriadcs ct al., 2002, Strickbcrgcr
ct al., 2006). 8ascd on mortality risk, thc causcs ol syn
copc may bc dividcd into cardiac, noncardiac, or unknown
(Sotcriadcs ct al., 2002). SH is a wcllcstablishcd major
TABLE . LongTcrm Risk Stratication ol Syncopc
Risk stratication ol paticnts with
syncopc:
a
Risk lactors
Abnormal CG
History ol vcntricular arrhythmia
History ol congcstivc hcart lailurc
Agc ~45 ycars
sscrvatorio pidcmiologico dclla Sincopc
ncl Lazio (S!L):
b
Risk lactors
Agc ~65 ycars
History ol cardiovascular discasc
Lack ol prodromcs
Abnormal CG
STcPS:
c
Prcdictors ol longtcrm outcomcs
(1ycar) by multivariant analysis
\cntricular arrhythmias
Agc ~65 ycars
Ncoplasms
Ccrcbrovascular discasc
Structural hcart discasc
utcomcs: Arrhythmia or 1ycar mortality
0 incidcncc lor no risk lactors
27 incidcncc lor thrcc to lour risk lactors
utcomcs: 1ycar mortality
0 incidcncc lor no risk lactor
0.8 incidcncc lor onc risk lactor
19.6 incidcncc lor two risk lactors
34.7 incidcncc lor thrcc risk lactors
57.1 incidcncc lor lour risk lactors
utcomcs (9.3 ovcrall incidcncc)
cath (6)
Major thcrapcutic proccdurcs (3.3):
CPR, paccmakcr or !C inscrtion, and
!CU admission
a
Martin ct al. (1997).
b
Colivicchi ct al. (2003).
c
Costantino ct al. (2008).
70 Thanavaro
Diagnosis of Syncope
8oth Amcrican Hcart Association/Amcrican Collcgc ol
Cardiology Foundation (AHA/ACCF) and SC havc
cstablishcd guidclincs lor thc cvaluation ol syncopc (8ri
gnolc ct al., 2004, Strickbcrgcr ct al., 2006). thcr studics
havc also prcscntcd various diagnostic approachcs (Am
mirati ct al., 2000, Kapoor, 2002, Shcn ct al., 2004). 8ascd
on thcsc guidclincs and prior studics, an algorithm lor
thc cvaluation ol syncopc is suggcstcd (Figurc 2) (Am
mirati ct al., 2000, 8rignolc ct al., 2004, Kapoor, 2002,
Shcn ct al., 2004, Strickbcrgcr ct al., 2006). Tc initial
clinical cvaluation ol a paticnt with syncopc includcs a
carclul history and a physical cxamination including su
pinc and upright blood prcssurc mcasurcmcnts and CG
(Alboni ct al., 2001, Ammirati ct al., 2000, 8rignolc ct
al., 2004, Kapoor, 2002, Strickbcrgcr ct al., 2006). Asscss
ing thc mcdication list is ncccssary to cxcludc agcnts that
may prccipitatc orthostatic or arrhythmia rclatcd syncopc
(Strickbcrgcr ct al., 2006). Tc paticnts agc is important
inlormation bccausc thc causcs ol syncopc arc highly
tilttablc tcsting, and cardiology or ncurology consul
tations. Paticnts arc admittcd dircctly to this SMU
lrom thc and rcccivc thcir initial carc lor 6 hours
bclorc thcy arc dischargcd lor outpaticnt tcsting or ad
mittcd to thc hospital lor lurthcr cvaluation (Shcn
ct al., 2004). Tc Syncopc valuation in thc mcrgcncy
cpartmcnt Study idcnticd !01 intcrmcdiatcrisk pa
ticnts with syncopc according to thc ACP clinical policy
and randomizcd thcm to rcccivc standard carc or cvalu
ation in an SMU (Hu ct al., 2007, Shcn ct al., 2004).
Tc SMU cvaluation in this study incrcascd prcsumptivc
diagnosis and actuarial survival and rcduccd hospital ad
mission and lcngth ol hospital stay (Shcn ct al., 2004). A
standardizcdcarc pathway that incorporatcd Vcbbascd
intcractivc SC guidclinc soltwarc was uscd in a dicr
cnt study to cvaluatc 74 paticnts with syncopc in thc
(GSYS2) ( 8rignolc ct al., 2004, 8rignolc, Ungar, ct al.,
2006). Usc ol thc standardizcd carc pathway dccrcascd
hospital admission and lcngth ol hospital stay and im
provcd diagnosis at a lowcr ovcrall cost (8rignolc, Ungar,
ct al., 2006).
Figure 2. iagnostic stratcgics lor syncopc.
Evaluation and Management of Syncope 71
(8rignolc ct al., 2004). Tc diagnosis ol syncopc is cstab
lishcd altcr thc initial cvaluation in 50 ol all paticnts
and trcatmcnt stratcgics may bc initiatcd (8rignolc ct al.,
2004). !n onc study, thc NMS accounts lor up to two
thirds ol thc initial and subscqucnt diagnosis ol syncopc
lollowcd by cardiac rclatcd and orthostatic syncopc
(8rignolc ct al., 2004).
Paticnts with a suspcctcd diagnosis will nccd spc
cic tcsting to conrm or rulc out thc diagnosis ( 8rignolc
ct al., 2004, Kapoor, 2002). Paticnts with possiblc NMS
or orthostatic syncopc arc rccommcndcd to havc a tilt
tablc tcst or carotid sinus massagc (CSM) (8rignolc ct al.,
2004, Strickbcrgcr ct al., 2006). Tc long intcrval bctwccn
cpisodcs ol NMS may contributc to a normal convcn
tional tcsting (tilttablc tcst and CSM), and a ncgativc
tcst rcsult docs not ncccssary cxcludc thc diagnosis
(Alboni ct al., 200!, 8rignolc, Sutton, ct al., 2006, Mai
scl, 2004). arly application ol an intcrnal loop rccordcr
(!LR) was rcccntly lound to cstablish morc diagnoscs with
suspcctcd NMS than convcntional tcsting (8rignolc, Sut
ton, ct al., 2006). Paticnts with suspcctcd cardiac syncopc
will rcquirc an cchocardiogram and cxcrcisc strcss tcsting
(8rignolc ct al., 2004, Strickbcrgcr ct al., 2006). Cardiac
arrhythmias arc thc major causcs ol syncopc in paticnts
with SH and prolongcd cardiac monitoring or clcctro
physiologic (P) studics may bc ncccssary to uncovcr thc
plausiblc cardiac arrhythmia (Kapoor, 2002, Strickbcrgcr
ct al., 2006). !l thc initial workup lor suspcctcd syncopc
is normal, rccvaluation ol thc paticnts and tcsting rcsults
may warrant additional asscssmcnt lor NMS or cardiac
syncopc or spccialty consultation (8rignolc ct al., 2004,
Kapoor, 2002).
8ccausc ol a high incidcncc ol mortality associatcd
with cardiac syncopc, thc rst stcp in cvaluating rccurrcnt
uncxplaincd syncopc is to cxcludc any undcrlying SH
and to makc surc that paticnts do not havc unrccognizcd
cardiac syncopc (Kapoor, 2002). An cchocardiogram and
strcss tcst arc rccommcndcd lor cldcrly paticnts without
clinical cvidcncc ol SH and lor paticnts with a history
ol cxcrcisc induccd syncopc (Strickbcrgcr ct al., 2006).
Tc tcsting stratcgics in paticnts with uncxplaincd syn
copc and normal CGs and cardiac cxamination dcpcnd
on thc scvcrity and lrcqucncy ol syncopc (8rignolc ct al.,
2004, Strickbcrgcr ct al., 2006). Paticnts with a rst bc
nign cpisodc ol syncopc and without cvidcncc ol SH
havc a high probability ol having NMS, a low risk lor
cardiac syncopc, and a good prognosis (Sotcriadcs ct al.,
2002). Tcsc paticnts do not rcquirc additional workup
lor cardiac arrhythmias (8rignolc ct al., 2004, Kapoor,
2002, Strickbcrgcr ct al., 2006). 8ccausc ol thc risk ol
agc dcpcndcnt (Strickbcrgcr ct al., 2006). Pcdiatric and
young paticnts arc morc likcly to havc NMS and cardiac
arrhythmiarclatcd syncopc such as thc LQTS or VPV
syndromc. NMS is thc most lrcqucnt causc ol syncopc in
middlcagcd paticnts. ldcrly paticnts commonly havc a
highcr incidcncc ol cardiac syncopc and may also cxpcri
cncc situational NMS and orthostatic syncopc.
A pcrtincnt clinical history includcs prodromal
symptoms, prccipitating cvcnts, prior cardiac history,
lamily history ol SC, and thc dcscription ol thc cvcnt
by any witncss (8rignolc ct al., 2004, Strickbcrgcr ct al.,
2006). Tc diagnosis ol NMS or orthostatic syncopc is
dctcrmincd largcly by thc dcscription ol thc prccipitating
cvcnt, clinical prcscntation, and charactcristics ol syncopc
(8rignolc ct al., 2004, Strickbcrgcr ct al., 2006). Chcst
pain, shortncss ol brcath, palpitations, and syncopc in a
supinc position or during cxcrcisc is indicativc ol pos
siblc cardiacrclatcd syncopc (Alboni ct al., 200!, Kapoor,
2002, Strickbcrgcr ct al., 2006).
Physical cxamination may dctcct undcrlying cardio
vascular discasc, such as irrcgular pulscs, hcart murmurs,
carotid bruits, or pulsc dicrcntial (Strickbcrgcr ct al.,
2006). Additionally, thc scvcrity ol syncopc may bc as
scsscd by thc cvidcncc ol physical injury and classicd as
bcnign with minor injury and malignant with scvcrc injury
(Strickbcrgcr ct al., 2006). 8lood prcssurc mcasurcmcnt in
both arms and in supinc and upright positions will hclp
cstablish thc diagnosis ol subclavian obstruction or ortho
static hypotcnsion. A blood prcssurc dicrcncc ol 20 mm
Hg bctwccn both arms is suggcstivc ol subclavian obstruc
tion (Lobato, Kcrn, 8audcrHcit, Hughcs, & Sulck, 200!).
rthostatic hypotcnsion is dcncd as a blood prcssurc
drop ol at lcast 20/!0 mm Hg or morc with a changc in
position lrom supinc to standing (8rady & avis, 2001).
8lood prcssurc should bc mcasurcd minutcs altcr thc
paticnt rcsumcs a supinc position and 1 minutcs altcr thc
paticnt stands up (Kapoor, 2002). An abnormal CG is
hclplul in cstablishing thc prcscncc ol cardiac arrhyth
mia or SH as thc causc ol thc syncopc. Tc CG may
dcmonstratc abnormal A\ conduction, bundlc branch
block or abnormal Q wavcs, or STT changcs consistcnt
with ischcmic cardiac discasc, acccssory pathways, LQTS,
or 8rugada syndromc (8rignolc ct al., 2004, Strickbcrgcr
ct al., 2006).
Diagnostic Strategies
Altcr thc initial cvaluation paticnts may bc catcgorizcd
into thrcc groups: paticnts with a dcnitivc diagnosis,
suspcctcd diagnosis, and uncxplaincd syncopc (Figurc 2)
72 Thanavaro
2005). Pharmacologic provocation with sublingual nitro
glyccrinc, !suprcl, or adcnosinc triphosphatc inlusion is
occasionally administcrcd during this tcst (8rignolc ct al.,
2004, 8arnsquivias & MartnczRubio, 2003). Tilt
tablc tcsting is considcrcd positivc il thc paticnt dcvclops
hypotcnsion and markcd bradycardia or asystolc associ
atcd with symptoms similar to thosc ol spontancous NMS
(Hainsworth, 2003). Symptomatic hypotcnsion without
bradycardia is indicativc ol orthostatic syncopc.
Echocardiogram
Tc cchocardiogram providcs diagnostic and prognostic
inlormation on SH that prcdisposcs paticnts to syncopc,
including thc asscssmcnt ol cardiac sizc, lcltvcntricular
lunction, wall motion, and valvular hcart discasc (Chcitlin
ct al., 2003, Strickbcrgcr ct al., 2006). !t has also bccomc an
cstablishcd tool lor diagnosing CA and is thc primary
mcthod lor thc diagnosis ol aortic stcnosis, congcstivc or
hypcrtrophic cardiomyopathy, and atrial myxoma (Chcitlin
ct al., 2003).
Exercise Stress Test
xcrcisc strcss tcsting in paticnts with syncopc is pcr
lormcd to idcntily CA and cxcrciscinduccd cardiac
arrhythmias such as sinus nodc dyslunction, A\ block,
or tachycardias (Gibbons ct al., 2002). Failurc to incrcasc
systolic blood prcssurc 10 to 30 mm Hg during cxcrcisc
strcss tcsting may indicatc signicant SH, such as lclt
main stcnosis or obstructivc cardiomyopathy (Gibbons
ct al., 2002, McKcnna, & 8chr, 2002).
Cardiac Monitoring
!nhospital cardiac monitoring is warrantcd whcn thc
paticnt has cvidcncc ol SH and is at high risk ol a lilc
thrcatcning arrhythmia (8rignolc ct al., 2004). Prolongcd
CG monitoring is indicatcd il thc initial cvaluation
shows a high probability ol cardiac arrhythmiarclatcd
syncopc or uncxplaincd syncopc with normal tcsting lor
NMS and without SH (8rignolc ct al., 2004, Strick
bcrgcr ct al., 2006). Tc choicc ol outpaticnt cardiac
monitoring is bascd on thc lrcqucncy ol syncopc.
Holter
Tc Holtcr monitor is an cxtcrnal dcvicc that is uscd to
monitor thc CG tracing continuously lor a pcriod ol
24 hours or longcr. Tc dcvicc is small and may bc las
tcncd to thc paticnts bclt. !t rcquircs two or morc cxtcrnal
lcads that attach to clcctrodcs on thc chcst. Tc dcvicc is
physical injury and diminishcd quality ol lilc associatcd
with lrcqucnt syncopc, paticnts with multiplc uncxplaincd
cpisodcs (2) warrant lurthcr workup lor arrhythmic syn
copc (8rignolc & Shcn, 2008, Strickbcrgcr ct al., 2006).
Holtcr, cxtcrnal loop rccordcr (LR) or !LR arc appropri
atc tcsts lor paticnts with lrcqucnt syncopc, whcrcas !LR
is a bcttcr choicc lor paticnts with inlrcqucnt cpisodcs
(Strickbcrgcr ct al., 2006). ocumcntcd normal sinus
rhythm during thc cpisodc ol syncopc cxcludcs arrhyth
miarclatcd syncopc as wcll as NMS, thcsc paticnts arc
not at risk ol having scrious outcomcs, and thcy do not
rcquirc additional cardiac tcsting (Strickbcrgcr ct al.,
2006). Tosc with rccordcd arrhythmias during symptoms
will nccd appropriatc trcatmcnt lor cithcr bradycardia or
tachycardia (8ocrsma, Mont, Sionis, Garca, & 8rugada,
2004, Moya ct al., 200!, Zipcs ct al., 2006).
Diagnostic Testing
Carotid Sinus Massage
Carotid sinus massagc is pcrlormcd to cvaluatc paticnts
with suspcctcd carotid sinus hypcrscnsitivity. Tis tcst may
bc pcrlormcd at thc bcdsidc with paticnts in thc supinc or
upright positions undcr continuous CG and blood prcs
surc monitoring (Millcr & Krusc, 2005, Strickbcrgcr ct al.,
2006). CSM is pcrlormcd onc sidc at a timc by applying
rm massagc lor 5 to 10 scconds at thc sitc ol most ap
prcciablc carotid pulsation. Carotid sinus hypcrscnsitivity
is diagnoscd whcn CSM causcs a 3sccond pausc, a 50
mm Hg lall in systolic blood prcssurc, or both, associatcd
with prcsyncopc or syncopc (Millcr & Krusc, 2005). !n
thc abscncc ol a rcsponsc, CSM is rcpcatcd on thc othcr
sidc 1 minutc latcr. CSM should not bc pcrlormcd in pa
ticnts with a history ol rcccnt transicnt ischcmic attack or
strokc or on a carotid artcry that has a signicant bruit or
known stcnosis (Strickbcrgcr ct al., 2006).
Tilt-Table Test
Tilttablc tcsting is also rclcrrcd to as hcadup tilt, which is
pcrlormcd in paticnts with suspcctcd NMS or orthostatic
syncopc. Tilttablc tcsting promotcs vcnous pooling in thc
lowcr cxtrcmitics and provokcs vasovagal rcsponsc through
thc 8czoldJarisch mcchanism lcading to bradycardia and
hypotcnsion in NMS (Hainsworth, 2003). Paticnts arc sc
curcd to a tilt tablc, and blood prcssurc and hcart ratc arc
monitorcd cvcry 2 minutcs lor 10 minutcs. Tc paticnts
arc thcn tiltcd upward at anglcs bctwccn 60 and 80 dcgrccs
lor 30 to 60 minutcs with rcgular monitoring ol clinical
rcsponsc, blood prcssurc, and hcart ratcs (Millcr & Krusc,
Evaluation and Management of Syncope 73
P tcsting (8ocrsma ct al., 2004, Krahn ct al., 2003,
Lombardi ct al., 2005).
Electrophysiologic Study
Tc clcctrophysiologic study is an invasivc proccdurc that
is rccommcndcd whcn cardiac arrhythmias arc suspcctcd
to bc thc causc ol syncopc and noninvasivc diagnostic
studics arc not conclusivc (Strickbcrgcr ct al., 2006).Tc
P tcsting is indicatcd in paticnts who havc uncxplaincd
syncopc in thc prcscncc ol impaircd lcltvcntricular lunc
tion or SH (Strickbcrgcr ct al., 2006, Zipcs ct al., 2006).
Tis study is also rccommcndcd in paticnts with highrisk
occupations in whom cvcry cort is ncccssary to cxcludc
a cardiac causc ol syncopc (8rignolc ct al., 2004). Tc
yicld ol P studics dcpcnds on thc prcscncc ol undcrly
ing SH: both bradycardia (34 vs. 10) and \T (21
vs. 1) arc morc induciblc in paticnts with than thosc
without hcart discasc (Linzcr ct al., 1997). P induc
tion ol polymorphic \T or vcntricular brillation (\F)
is prcdictivc ol syncopal cvcnts in paticnts with 8rugada
syndromc, survivors ol SC with CA, and idiopathic
\F, but it is lcss prcdictivc in paticnts with dilatcd car
diomyopathy (8rignolc ct al., 2004, 8rilakis ct al., 2001,
8rugada ct al., 2003).
Treatment
Neurally Mediated Syncope
!t is important to inlorm thc paticnt that NMS is normally
not lilc thrcatcning but that injurics can occur il prcvcntivc
mcasurcs arc not appropriatcly takcn (8cnditt & Nguycn,
2009). Paticnt cducation is an important part ol thc trcat
mcnt lor NMS. Tc paticnts undcrstanding ol thc mccha
nism and warning symptoms may rcducc injurics and
incrcasc trcatmcnt compliancc(8cnditt & Nguycn, 2009,
Kapoor, 2002). Tc mcchanism ol NMS is hctcrogcncous,
vasodilatation is thc ccntral part ol this clinical cntity, and
scvcrc bradycardia or asystolc contributcs to about onc
hall ol thc cvcnts (8rignolc, Sutton, ct al., 2006, Kapoor,
2003). Mcdical trcatmcnt lor NMS includcs avoiding dc
hydration, physical countcrprcssurc mancuvcrs (PCM) at
thc onsct ol prodromc (lying down with thcir lcct poppcd
up, squatting, isomctric hand gripping, arm tcnsing, and
lcg crossing), incrcasing in intravascular volumc by oral or
intravcnous uids and dictary salt, wcaring support hosc,
and physical tilt training (8cnditt & Nguycn, 2009, 8rig
nolc ct al., 2004, Kapoor, 2002, 2003, Tan & Parry, 2008).
Tilt training (standing training) promotcs ncurovascular
tolcrancc to orthostatic strcss, thc rccommcndcd standing
rcturncd to a diagnostic ccntcr lor data analysis at thc cnd
ol thc rccording scssion. Holtcr monitoring is indicatcd to
capturc an arrhythmia that is suspcctcd to occur on a daily
basis, and thc ovcrall diagnostic yicld ol syncopc is low
(8.6) (Kuhnc, Schacr, Moulay, Stichcrling, & sswald,
2007, Strickbcrgcr ct al., 2006). Holtcr monitoring may
also rcvcal QTintcrval changcs, Twavc altcrnans, or ST
changcs (Strickbcrgcr ct al., 2006, Zipcs ct al., 2006).
External Loop Recorder
Tc cxtcrnal loop rccordcr is also rclcrrcd to as cvcnt rc
cordcr. !t is an cxtcrnal dcvicc that allows prolongcd con
tinuous ambulatory CG monitoring lor up to 60 days
(Gula ct al., 2004). Tc LR is a pagcrlikc dcvicc and
may bc lastcncd to thc paticnts bclt. Tc dcvicc has both
automatic and manual activation to lrcczc thc mcmory.
Tc storcd cardiac rhythm during thc cvcnt may bc trans
mittcd by a tclcphonc to a diagnostic ccntcr lor analysis.
Tc LR is uscd to cvaluatc sporadic syncopal cpisodcs,
which is suspcctcd to occur oncc cvcry 1 to 2 months,
and thc diagnostic yicld may vary bctwccn 15 and 50
(Strickbcrgcr ct al., 2006).
Implantable Loop Recorder
Tc implantablc loop rccordcr is an intcrnal monitor
ing dcvicc that is usclul lor thc diagnosis ol suspcctcd
arrhythmiarclatcd syncopc, particularly whcn thc cpi
sodcs arc inlrcqucnt and convcntional noninvasivc cardiac
tcsting is ncgativc or inconclusivc (Assar, Krahn, Klcin,
Ycc, & Skancs, 2003, 8rignolc ct al., 2004, 8rignolc,
Sutton, ct al., 2006, Krahn, Klcin, Ycc, Hoch, & Skancs,
2003, Moya ct al., 2001, Zipcs ct al., 2006). Tis dcvicc
is vcry small and is typically implantcd subcutancously in
thc lclt pcctoral rcgion as an outpaticnt proccdurc (Lom
bardi ct al., 2005). Tc !LR has clcctrodcs on thc back
ol thc dcvicc to dctcct paticnts cardiac rhythm and docs
not rcquirc intracardiac lcads. Tc unit is activatcd manu
ally by thc paticnt during a symptomatic cvcnt or by au
tomatic prcprogramming lor a vcntricular pausc ol ~3
scconds, lowcr (40 bpm) or high vcntricular ratc (~165
bpm) (Farwcll, Frccmantlc, & Sulkc, 2006, Moya ct al.,
2001, Strickbcrgcr ct al., 2006). ata arc rctricvcd with
a programmcr, and somc dcviccs also havc thc capability
to allow paticnts to scnd data dircctly to thcir hcalth carc
providcrs. Morc than 50 ol paticnts cxpcricncc symp
toms during thc 14month duration ol !LR monitoring,
and thc causc ol syncopc is cstablishcd morc oltcn with
!LR (47 vs. 20) and at a lowcr cost pcr diagnosis than
convcntional tcsting, which includcs LR, tilttablc, and
74 Thanavaro
rcvascularization or valvular surgcry (8cnditt & Nguycn,
2009, McKcnna & 8chr, 2002). !l cardiac arrhythmias
arc thc culprit lor syncopc in paticnts with SH, paticnts
will also nccd thcrapy lor bradycardia or tachycardia in
addition to thc trcatmcnt lor undcrlying SH (8ocrsma
ct al., 2004, Moya ct al.,2001, Zipcs ct al., 2006).
Cerebrovascular Syncope
Tc trcatmcnt ol ccrcbrovascular syncopc may bc ac
complishcd with surgical or pcrcutancous rcvasculariza
tion. Carotid cndartcrcctomy rcmains thc gold standard
lor hcmodynamically signicant carotid stcnosis and an
gioplasty, and stcnting is prcscntly bcing cvaluatcd as a
trcatmcnt option lor highrisk paticnts (8iggs & Moorc,
2007). 8oth pcrcutancous and surgical options appcar
to bc salc and rcasonably durablc lor subclavian stcnosis
(Rogcrs & Calhoun, 2007). Primary stcnt placcmcnt may
bc thc trcatmcnt ol choicc lor vcrtcbral artcrial discasc
(Cloud & Marcus, 2003).
Driving
Tc AHA cstablishcd driving guidclincs rclatcd to ar
rhythmias that may acct consciousncss that wcrc latcr
amcndcd to includc drivcrs with !C inscrtion lor pri
mary prcvcntion (pstcin ct al., 1996, 2007). Tc SC
also suggcstcd a guidclinc lor driving lor paticnts with
syncopc (8rignolc ct al., 2004). Two groups ol drivcrs arc
dcncd: privatc and commcrcial (8rignolc ct al., 2004,
pstcin ct al., 2007). rivcrs ol taxicabs, small ambu
lanccs, and othcr vchiclcs lorm an intcrmcdiatc catcgory
(8rignolc ct al., 2004). ata suggcst that thc risk lor a
motor vchiclc accidcnt rclatcd to syncopc is low (Aki
yama, Powcll, Mitchcll, hlcrt, & 8acsslcr, 2001). Tc
c cacy ol drug thcrapy lor NMS rcmains inconclusivc,
and rcpcat tilttablc tcsting to asscss thcrapy has no prc
dictivc valuc (8rignolc ct al., 2004, Kapoor, 2002). Tcrc
is no cvidcncc that allowing 3 asymptomatic months to
clapsc providcs assurancc that syncopc will not rccur (8ri
gnolc ct al., 2004). Tc SC guidclincs havc shortcncd or
climinatcd thc waiting duration ol asymptomatic pcriod
lor scvcrc NMS, postpaccmakcr inscrtion, or \T trcat
mcnt lor both privatc and commcrcial drivcrs (8rignolc
ct al., 2004, pstcin ct al., 2007).
riving rccommcndations should bc prcscribcd in con
junction with thc collaborating physician or cardiologist
(Tablc 4). !n gcncral, thcrc arc no rcstrictions or minimal
rcstrictions lor privatc drivcrs who sucr lrom syncopc with
a low incidcncc ol rccurrcncc or a low probability ol scrious
outcomcs during a rccurrcnt cpisodc, thcsc includc bcnign
duration is 3 to 5 minutcs twicc daily at rst with a gradual
incrcasc in standing duration cvcry 3 to 4 days, up to 30
to 40 minutcs twicc daily (8cnditt & Nguycn, 2009, Ka
poor, 2002). Somc paticnts may rcquirc pharmacothcrapy,
such as volumc cxpandcrs (udocortisonc), bcta blockcrs,
or vasoconstrictors and vcnucostrictors (Mcdodrinc) (8cn
ditt & Nguycn, 2009, Kapoor, 2002). Randomizcd con
trollcd trials havc dcmonstratcd no clcar clinical bcnct
ol thcsc agcnts, and thc paticnt should bc warncd ol pos
siblc associatcd sidc cccts ol hypcrtcnsion (dictary salt,
udocortisonc, or Mcdodrinc) or urinary rctcntion or ur
gcncy (Mcdodrinc) (8cnditt & Nguycn, 2009). Pcrmancnt
paccmakcr inscrtion is ccctivc only lor asystolc (Kapoor,
2002). Tc rccommcndation ol a pcrmancnt paccmakcr
inscrtion lor bradycardiarclatcd NMS rcmains contro
vcrsial, and additional studics arc ncccssary bclorc pacing
can bc considcrcd a standard thcrapy (8rignolc ct al., 2004,
Kapoor, 2002, 2003, Tan & Parry, 2008).
Orthostatic Syncope
Tc trcatmcnt ol orthostatic syncopc consists ol cducation
rcgarding aggravating lactors lor orthostatic syncopc, non
pharmacologic and pharmacologic corrcctions ol hypov
olcmia, and autonomic imbalancc (8cnditt & Nguycn, 2009,
8rady & avis, 2003). Tc nonpharmacologic approach lo
cuscs on making slow and carclul changcs in position, avoid
ing dchydration, incrcasing in intravascular volumc, wcaring
support hosc, and a routinc cxcrcisc program (8cnditt &
Nguycn, 2009, 8rady & avis, 2003). Tc paticnt may also
bcnct lrom PCM, tilt training, and slccping with thc hcad
ol thc bcd clcvatcd to 20 to 25 cm (8cnditt & Nguycn, 2009).
Pharmacothcrapy with volumc cxpandcrs or vasoconstric
tors may bc prcscribcd lor scvcrc symptoms ol orthostasis
(8cnditt & Nguycn, 2009, 8rady & avis, 2003).
Cardiac Arrhythmia-Related Syncope
Transicnt bradycardia is lrcqucntly rcsponsiblc lor cardiac
arrhythmiarclatcd syncopc and a cardiac paccmakcr is
rcquircd (8cnditt & Nguycn, 2009, 8ocrsma ct al., 2004,
Moya ct al., 2001). Tachycardia accounts lor thc rcmain
dcr ol arrhythmiarclatcd syncopc, and trcatmcnt options
includc antiarrhythmic thcrapy, cathctcr ablation, pacc
makcr, or !C inscrtion (Zipcs ct al., 2006).
SHD-Related Syncope
Paticnts with SH may rcquirc cithcr mcdical thcrapy,
cathctcrrclatcd proccdurcs, or surgical corrcction lor thc
trcatmcnt ol undcrlying cardiac discasc such as myocardial
Evaluation and Management of Syncope 75
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8rignolc, M., Alboni, P., 8cnditt, ., 8crglcldt, L., 8lanc, J.,
8loch Tomscn, P. ct al. (2004). Guidclincs on managcmcnt
vasovagal syncopc, carotid sinus syncopc, S\T, postpacc
makcr or prophylactic !C implantation, or uncxplaincd
syncopc (8rignolc ct al., 2004, pstcin ct al., 2007). A lon
gcr pcriod ol rcstriction is rccommcndcd lor paticnts with a
high likclihood ol causing an accidcnt during an cvcnt, thcsc
includc scvcrc vasovagal syncopc, vcntricular tachycardia, or
postthcrapcutic !C inscrtion. Tc driving guidclincs lor
commcrcial drivcrs arc morc rcstrictcd to cnsurc public
salcty (8rignolc ct al., 2004, pstcin ct al., 2007).
Conclusion
A high pcrccntagc ol syncopc rcmains undiagnoscd, and
an important task in cvaluating paticnts with syncopc is
to cxcludc undcrlying cardiac discasc bccausc thosc with
cardiac syncopc arc at risk ol having poor outcomcs, in
cluding suddcn cardiac dcath and allcausc mortality.
Nursc practitioncrs nccd a good undcrstanding ol thc
complcx mcchanisms ol syncopc and should lollow an
organizcd approach in cvaluating this common clinical
condition. For nursc practitioncrs with limitcd cxpcricncc
in managing thcsc paticnts, sccking collaborativc advicc
or rclcrring thc paticnt to a spccialist is rccommcndcd. !t
is csscntial to makc a corrcct diagnosis so that appropriatc
trcatmcnt may bc providcd to climinatc thc undcrlying
discasc and prcvcnt rccurrcnt syncopal cpisodcs.
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TABLE . riving Guidclincs
Typcs ol Syncopc
riving Rcstriction Altcr Trcatmcnt
Privatc rivcr Commcrcial rivcr
Ncurally mcdiatcd syncopc
a

\asovagal 8cnign (singlc/mild) No rcstriction 1 month
Scvcrc (lrcqucnt/highrisk activity) 3 months 6 months
Carotid sinus 1 month 1 month
Cardiac arrhythmiarclatcd syncopc
a
Supravcntricular tachycardia No rcstriction No rcstriction
\cntricular tachycardia Nonsustaincd 3 months 6 months
Sustaincd 6 months 6 months
Paccmakcr implant Nonpaccmakcr dcpcndcnt 1 wcck 1 wcck
Paccmakcr dcpcndcnt 1 wcck 4 wccks
!ntcrnal cardiovcrtcr dcbrillator Prophylactic 1 wcck Pcrmancnt
Tcrapcutic 6 months Pcrmancnt
Uncxplaincd syncopc
b
Altcr tcsting and trcatmcnt No rcstriction 3 months
a
pstcin ct al. (2007).
b
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