Syncope

Table 3. Pertinent Historical Information in the Evaluation

of Syncope

Features Possible diagnosis

Routine laboratory studies have low
Position before syncope
diagnostic yield and should be ordered only
Prolonged standing Neurally mediated syncope (vasovagal), orthostatic
if clinically indicated. Laboratory tests can hypotension syncope
distinguish syncope from other suspected Sudden change in posture* Orthostatic hypotension syncope
nontraumatic etiologies of loss of con- Supine* Cardiac syncope (arrhythmia, structural heart
sciousness. Elevated troponin and brain disease)
natriuretic peptide levels have been shown Postsyncope
to predict a higher likelihood of adverse Amnesia regarding loss of Seizure or neurally mediated syncope (vasovagal)
outcomes but should be used only if cardio- consciousness in older patients
vascular disease is clinically suspected.26,37,38 Eyes closed during event* Pseudoseizure, psychogenic pseudosyncope
ECG generally has a low diagnostic yield Eyes open during event Seizure or syncope (any cause)
(approximately 3% to 5%) but is recom- Fatigue, nausea, vomiting* Neurally mediated syncope (vasovagal)
mended for all patients with syncope.39,40 Focal neurologic deficit Neurogenic syncope (cerebrovascular accident or
Although arrhythmias are unlikely to transient ischemic attack)
be detected on a single ECG, ischemic, Immediate complete Cardiac syncope (arrhythmia), psychogenic
recovery pseudosyncope
structural, or conduction abnormalities
Incontinence Seizure (uncommon in syncope; vasovagal syncope
may be identified. Any ECG abnormality most likely)
or change from baseline increases the risk Myoclonic, tonic-clonic Neurally mediated syncope (vasovagal), seizure
of arrhythmia or death within one year of movement
the syncopal event.41 Prolonged confusion* Seizure
Echocardiography is essential to evalu- Prolonged syncope Seizure, neurogenic, metabolic, infectious
ate suspected structural abnormalities, but Slow pulse Cardiac syncope (bradyarrhythmia)
it generally has low diagnostic yield. Two Tongue biting* Seizure
studies (n = more than 310) found echocar- Transient disorientation Neurally mediated syncope (vasovagal)
diography to be clinically useful in patients Precipitating factors
with syncope if there is a history of cardiac Activities such as coughing, Neurally mediated syncope (situational)
disease, abnormal ECG findings, or sus- defecation, eating,
pected significant valvular disease.42,43 laughing, urination*
Continuous cardiac monitoring is the Emotional distress, fear, Neurally mediated syncope (vasovagal)
pain, prolonged standing,
diagnostic standard to establish a corre-
warm or crowded area*
lation between symptoms and ECG find- Exertion* Cardiac syncope (arrhythmia, structural heart
ings. Devices include Holter monitors disease)
(generally up to 72 hours), external loop Hand or upper extremity Subclavian steal syndrome
recorders (typically four to six weeks), and exercise
implantable loop recorders (up to three Head movement, shaving, Neurally mediated syncope (carotid sinus)
years). The diagnostic yield improves tight collar*

with prolonged monitoring. Up to 50% Medication use

Antiarrhythmics Cardiac syncope (arrhythmia, prolonged QT interval)
of patients who present with syncope in
Antihypertensives Orthostatic hypotension syncope, cardiac syncope
the absence of heart disease will have an
(prolonged QT interval)
arrhythmia when an implantable loop Macrolides, antiemetics, Cardiac syncope (prolonged QT interval)
recorder is placed.44 These devices may antipsychotics, tricyclic
increase diagnostic yield, decrease time to antidepressants
diagnosis, and improve cost-effectiveness. Postexertion Neurally mediated syncope (vasovagal), cardiac
Some guidelines recommend them early syncope (arrhythmia)

in the diagnostic workup of unexplained
syncope.45-48 Patients most likely to benefit
from these devices are those with cardio-
vascular disease, abnormal baseline ECG
findings, cardiac symptoms surrounding
the syncopal event, and a family history
of sudden cardiac death.39
Standing after prolonged Orthostatic hypotension syncope
sitting
Unexplained fall Neurally mediated syncope (carotid sinus), cardiac
syncope (arrhythmia, structural heart disease)
continues
*—Salient features from history for differentiation.

308 American Family Physician www.aafp.org/afp Volume 95, Number 5 ◆ March 1, 2017