Premonitory symptoms (e.g., nausea, dizziness) or precipitating factors Mediated by stress, fear, noxious stimuli, heat exposure Micturition, post-exercise, postprandial, gastrointestinal stimulation, cough, phobia of needle or bloodĪbsence of heart disease, history of similar syncope, prolonged standing, eating a meal or voiding, sudden startle or pain Perform carotid sinus massage ventricular pause more than three seconds or decrease in systolic blood pressure ≥ 50 mm Hg is diagnostic Head rotation or pressure on the carotid sinus (e.g., shaving, tight collar) can reproduce symptoms consider in patients with unexplained falls Often asymptomatic, may cause shortness of breath and fatigue Severe sharp chest pain with or without radiation to the back, hypotension or shock, history of hypertension Rare as an isolated finding in adults, often in association with congenital defects symptoms based on severity and range from asymptomatic to shortness of breath/dyspnea on exertion, congestive heart failure, and syncopeĮxertional chest pain, nausea, diaphoresis and shortness of breath rare cause of syncopeĪcute shortness of breath, chest pain, hypoxia, sinus tachycardia or right heart strain Symptoms dependent on severity severe aortic stenosis can manifest with congestive heart failure, syncope, or angina usually with exertion Often asymptomatic may cause shortness of breath, chest pain, arrhythmia, or syncope hypertrophic cardiomyopathy may cause systolic murmur that intensifies from squatting to standing or during Valsalva maneuver Presence of heart disease, family history of sudden death, symptoms during or after exertion, sudden onset of palpitations, electrocardiographic abnormalities Generally abrupt and unprovoked, palpitations may precede symptoms Patients at low risk of adverse events (i.e., those with symptoms consistent with vasovagal or orthostatic syncope, no history of heart disease, no family history of sudden cardiac death, normal electrocardiographic findings, unremarkable examination, and younger patients) may be safely followed without further intervention or treatment.Īrrhythmia (e.g., bradyarrhythmias, ventricular tachyarrhythmias, supraventricular tachyarrhythmias, long QT syndrome), pacemaker dysfunction Indications for electrophysiology include patients with coronary artery disease and syncope, coronary artery disease with an ejection fraction less than 35 percent, and possibly nonischemic dilated cardiomyopathy. Laboratory testing in the evaluation of syncope should be ordered as clinically indicated by the history and physical examination. Patients with syncope and evidence of heart failure or structural heart disease should be admitted to the hospital for monitoring and evaluation.Īll patients presenting with syncope should have orthostatic vital signs and standard 12-lead electrocardiography. Although a subset of patients will have unexplained syncope despite undergoing a comprehensive evaluation, those with multiple episodes compared with an isolated event are more likely to have a serious underlying disorder. In cases of unexplained syncope, further testing such as echocardiography, grade exercise testing, electrocardiographic monitoring, and electrophysiologic studies may be required. Patients with neurally mediated or orthostatic syncope usually require no additional testing. Patients with cardiovascular disease, abnormal electrocardiography, or family history of sudden death, and those presenting with unexplained syncope should be hospitalized for further diagnostic evaluation. All patients presenting with syncope require electrocardiography, orthostatic vital signs, and QT interval monitoring. Guidelines suggest an algorithmic approach to the evaluation of syncope that begins with the history and physical examination. Useful clinical rules to assess the short-term risk of death and the need for immediate hospitalization include the San Francisco Syncope Rule and the Risk Stratification of Syncope in the Emergency Department rule. Patients presenting with syncope (other than neurally mediated and orthostatic syncope) are at increased risk of death from any cause. Common nonsyncopal syndromes with similar presentations include seizures, metabolic and psychogenic disorders, and acute intoxication. Older adults are more likely to have orthostatic, carotid sinus hypersensitivity, or cardiac syncope, whereas younger adults are more likely to have vasovagal syncope. It is classified as neurally mediated (i.e., carotid sinus hypersensitivity, situational, or vasovagal), cardiac, orthostatic, or neurogenic. Syncope is a transient and abrupt loss of consciousness with complete return to preexisting neurologic function.
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