An Approach to Syncope

Diagnostic Framework

Reflex Syncope Cardiogenic Syncope Orthostatic Syncope Syncope Mimics

Vasovagal syncope Bradyarrhythmias Volume depletion Seizure

• Prolonged standing • Sinus bradycardia
• Emotional stress • Sinus pauses
Medication side effect “Cerebrovascular syncope”
• Blood draw • AV block
(e.g. α blockers, antidepressants, • Vertebrobasilar insufficiency
• Severe pain (particularly
antipsychotics) • Subclavian steal syndrome
intraabdominal)
Tachyarrhythmias
• Ventricular tachycardia
Autonomic failure Alcohol blackout
Situational syncope
• Parkinson’s disease
• Coughing
Mechanical • Diabetes
• Sneezing Medication side effect
• Aortic stenosis • Alcoholism
• Micturition (e.g. sedation)
• Hypertrophic • Amyloidosis
• Defecation
cardiomyopathy • Multiple system atrophy
• Post-exercise
• Massive PE Psychogenic pseudosyncope

Carotid sinus hypersensitivity

Eric Strong / Strong Medicine; Copyright 2019

Creative Commons 4.0 BY-NC-ND

Prodrome – A constellation of nausea,
lightheadedness, diaphoresis,
and/or visual disturbances
that can precede the loss of
consciousness for several
seconds to several minutes.
Presyncope – The occurrence of a prodrome
without a subsequent loss of
consciousness.
Important Questions to Ask of a
Patient Presenting With Syncope
What were you doing immediately before?
Did you have any symptoms immediately
preceding? (i.e. a prodrome)
Did you injure yourself in the fall?
How long were you unconscious?
When you awoke, how long did it take for
you to feel back to normal?
Was the event witnessed?
 Unlikely syncope. Consider:
• Medication side effect
• Alcohol blackout
Duration of loss of > 5 min • Drug intoxication
consciousness • Concussion
• Narcolepsy
• OSA-related
≤ 5 min hypersomnolence

Were the following features

present?
• Tonic-clonic movements during Yes
the loss of consciousness Probable seizure
• Bladder/bowel incontinence
• Post-event confusion lasting
more than a few minutes

No

Probable syncope
 Reflex Syncope Cardiogenic Syncope Orthostatic Syncope
(relatively benign) (relatively dangerous) (relatively benign)
Usually precipitated by clearly identifiable Usually no precipitant, or precipitated by Precipitated by moving from
Precipitant
trigger exertion lying/sitting to standing position

Prodrome Present Present or absent Present

Injury during fall Uncommon Common Uncommon

Age of onset Typically younger Typically older Typically older

Notable risk Heart failure, CAD, family history of early Parkinson’s disease, diabetes,
None
factors sudden cardiac death alcoholism, new prescriptions
Relevant exam Pathologic murmur consistent with
None Orthostatic hypotension
findings mechanical etiologies
Either current arrhythmia, evidence of
ischemia or occult CAD, or evidence of a
ECG findings None None
proarrhythmia syndrome (e.g. long QT,
delta waves, etc…)

If vasovagal or situational, additional Complete cardiovascular exam Diagnostic trial of IV fluids to

testing usually unnecessary, but correct possible dehydration
Diagnostic
ambulatory ECG monitor can be considered Echocardiogram
next steps: Stop possibly causative meds,
Carotid hypersensitivity can be Ambulatory ECG monitor if feasible
confirmed by carotid sinus massage