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In the evaluation of patients with syncope, the critical first step is a detailed medical history. A diagnostic strategy based on initial evaluation is warranted. The importance of the initial evaluation goes well beyond its capability to make a diagnosis as it determines the most appropriate subsequent diagnostic pathways and risk evaluation.
Several disorders may resemble syncope in two different ways. In some, consciousness is truly lost, but the mechanism is not related to cerebral hypoperfusion: Among cardiac investigations, echocardiography, prolonged electrocardiographic monitoring, stress test, electrophysiological study and implantable loop recorder are most useful.
BP, blood pressure; ECG, electrocardiogram. Initial evaluation may lead to a certain diagnosis based on symptoms, physical signs, or ECG findings.
Under such circumstances, no further evaluation may be needed and treatment, if any, can be planned. The results of the initial evaluation are most often diagnostic of the cause of syncope in the following situations:. However, it is important to bear in mind that syncope is often multifactorial.
The latter is especially true in older individuals. Thus, careful consideration should be given to multiple potential interacting factors for example, diuretics in older patients already susceptible to orthostatic hypotension, myocardial ischaemia in the setting of moderate aortic stenosis, etc. The presence of suspected or certain heart disease is associated with a higher risk of arrhythmias and mortality at one year.
In these patients, cardiac evaluation echocardiography, stress testing, electrophysiological study and prolonged ECG monitoring including loop recorder is recommended. It includes tilt testing, carotid sinus massage, and ECG monitoring, and often further requires implantation of an implantable loop recorder ILR.
Neurologic disease may cause transient loss of consciousness for example, certain seizures , but is almost never the cause of syncope. Thus, neurologic testing may be needed to distinguish seizures from syncope in some patients, but these should not be considered as essential elements in the evaluation of the basis of true syncope.
The possible contribution of electroencephalography EEG , computed tomography and magnetic resonance imaging of the brain is to disclose abnormalities caused by epilepsy; there are no specific EEG findings for any loss of consciousness other than epilepsy. Accordingly, several studies conclusively showed that EEG monitoring was of little use in unselected patients with syncope.
Thus, EEG is not recommended for patients in whom syncope is the most likely cause for a transient loss of consciousness. Carotid TIAs are not accompanied by loss of consciousness. Therefore, carotid Doppler ultrasonography is not required in patients with syncope. If the diagnosis is confirmed, treatment may be initiated; if not, a reappraisal process may be useful.
The cause of syncope may remain unexplained after the initial evaluation. If new clues to possible cardiac or neurological disease are yielded, further cardiac and neurological assessment are recommended. In these circumstances, consultation with appropriate specialists may be useful.
Psychiatric assessment is recommended in patients with frequent recurrent syncope who have many other somatic complaints and initial evaluation raises concerns about stress, anxiety and possible other psychiatric disorders.
The EGSYS study 5 was a prospective systematic evaluation—based on strict adherence to the Guidelines on Syncope of the ESC—of consecutive patients referred for syncope to the emergency departments of several general hospitals. Apart from the initial evaluation, a mean SD of 1.
A major issue in the use of diagnostic tests is that syncope is a transient symptom and not a disease. Typically patients are asymptomatic at the time of evaluation and the opportunity to capture a spontaneous event during diagnostic testing is rare.
This type of reasoning leads, of necessity, to uncertainty in establishing a cause. However, arriving at the diagnosis can be difficult, and is often marked by the undertaking of costly and often useless diagnostic procedures. The ultimate goal of diagnostic testing is to establish a sufficiently strong correlation between syncope and detected abnormalities to permit both an assessment of prognosis and initiation of an appropriate treatment plan.
Knowledge of what occurs during a spontaneous syncopal episode is ideally the gold standard for syncope evaluation. For this reason it is likely that ILRs will become increasingly important in the assessment of the syncope patient, and their use will increasingly be appropriate instead of, or before, many current conventional investigations.
This early ILR approach implies the need for a careful initial risk stratification in order to exclude from such a strategy patients with potential life threatening conditions.
Patients who seek medical advice after having experienced a vasovagal faint require reassurance and education regarding the nature of the disease and the avoidance of triggering events. In general, education and reassurance are sufficient for most patients.
Modification or discontinuation of hypotensive drug treatment for concomitant conditions and avoidance of triggering situations are other first line measures for the prevention of syncope recurrences. Treatment is not necessary for patients who have sustained a single syncope and are not having syncope in a high risk setting.
However, this treatment is hampered by the low compliance of the patients in continuing the training programme for a long period. Etilefrine proved to be ineffective. The role of cardiac pacing for vasovagal syncope is not yet established. Specifically, the efficacy of pacemaker therapy was questioned after two recent controlled trials failed to prove superiority of cardiac pacing over placebo of unselected patients with positive tilt testing.
A recent study using the ILR as reference standard 26 showed that only about half of the patients had an asystolic pause recorded at the time of spontaneous syncope. Thus, cardiac pacing should be limited as a last resort choice to a very selected small proportion of patients affected by severe vasovagal syncope.
Cardiac pacing appears to be beneficial in the carotid sinus syndrome and, although only one relatively small randomised controlled trial has been undertaken, pacing is acknowledged to be the treatment of choice when bradycardia has been documented. The principal treatment strategy is elimination of the offending agents, mainly diuretics and vasodilators. Alcohol is also commonly associated with orthostatic intolerance. Additional treatment principles, used alone or in combination, are appropriate for consideration on an individual patient basis 1 , Treatment is best directed at amelioration of the specific structural lesion or its consequences.
National Center for Biotechnology Information , U. Journal List Heart v. This article has been cited by other articles in PMC. Three key questions should be addressed during the initial evaluation: Is loss of consciousness attributable to syncope or not?
Are there features in the history that suggest the diagnosis? Accurate history taking alone is a key stage and often leads to the diagnosis or may suggest the strategy of evaluation. Is heart disease present or absent? The absence of signs of suspected or overt heart disease virtually excludes a cardiac cause of syncope with the exception of syncope accompanied by palpitations which could be due to paroxysmal tachycardia especially paroxysmal supraventricular tachycardia.
Open in a separate window. The triggering events might vary considerably in individual patients. These forms are diagnosed by minor clinical criteria, exclusion of other causes for syncope absence of structural heart disease and positive response to tilt testing or carotid sinus massage.
This occurs when the autonomic nervous system is incapacitated and fails to respond to the challenges imposed by upright position. The results of the initial evaluation are most often diagnostic of the cause of syncope in the following situations: Classical vasovagal syncope is diagnosed if precipitating events such as fear, severe pain, emotional distress, instrumentation or prolonged standing are associated with typical prodromal symptoms.
Situational syncope is diagnosed if syncope occurs during or immediately after urination, defaecation, cough or swallowing. Diagnosis and treatment of syncope: The initial evaluation may lead to certain diagnosis, or suspected diagnosis that needs to be confirmed by appropriate diagnostic tests, or no diagnosis.
The strategy of evaluation varies according to the severity and frequency of the episodes and the presence or absence of heart disease. In general, the absence of suspected or certain heart disease excludes a cardiac cause of syncope. Most patients with syncope require only reassurance and education regarding the nature of the disease and the avoidance of triggering events. Treatment may be warranted when: Structural cardiac or cardiopulmonary disease Treatment is best directed at amelioration of the specific structural lesion or its consequences.
Europace 6 — Eur Heart J 25 — J Am Coll Cardiol 37 — Eur Heart J 27 78— G Ital Cardiol 29 — Europace 5 — Does the use of a syncope diagnostic protocol improve the investigation and management of syncope? Heart 90 52— Eur Heart J 23 — Diagnosing syncope in the clinical practice.
Eur Heart J 21 — Pacing Clin Electrophysiol 21 — J Am Coll Cardiol 40 — Circulation — Am J Cardiol 70 — Am J Cardiol 78 — Cardiologia 43 — Pacing Clin Electrophysiol 25 — The Vasovagal Syncope International Study. Circulation 99 — Pacemaker versus no therapy: A multicenter, randomized, controlled trial. Circulation 52—
THE DIAGNOSTIC STRATEGY BASED ON THE INITIAL EVALUATION
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