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Characterize symptoms


Medication history


Past medical history


Possible triggers


Physical examination


Labs and tests


Imaging studies


Diagnostic features




Non syncope loss of consciousness


Known etiology
❑ Cardiovascular
❑ Orthostatic hypotension
❑ Reflex


Unknown etiology
Determine if there are any high risk criteria:


Consider additional tests


High risk


low risk


Consider alternative diagnoses


Immediate in-hospital monitoring


Recurrent syncopes


Single syncope


If suspicion of structural hear disease:
❑ Order an echocardiography


Was it in high risk setting?
❑ Potential risk of physical injury
❑ Occupational implications


Structural heart disease present
Treat accordingly


No structural heart disease




No: No further evaluation


Tilt testing


Characterize symptoms

Loss of consciousness (LOC)

❑ Rapid or slow onset
❑ Short or long duration
❑ Spontaneous complete recovery or incomplete recovery


❑ Warmth
Blurry vision

Chest pain (suggestive of cardiovascular syncope)
❑ Position prior to LOC:

Supine (suggestive of cardiovascular syncope)
Supine to erect posture (suggestive of orthostatic hypotension or reflex syncope)
❑ Prolonged standing (suggestive of reflex syncope)

❑ Activity prior to LOC: (suggestive of cardiovascular or reflex syncope)

❑ Driving
❑ Machine operation
❑ Flying
❑ Competitive athletics

❑ Bowel or bladder incontinence (suggestive of reflex syncope)

Obtain a detailed past medical history:

❑ Previously healthy
❑ Previous syncope episodes

❑ Time since previous episode
❑ Number of previous episodes

❑ Cardiovascular disease:

Heart block (LBBB, RBBB)
Valvular heart disease
Heart failure
Hypertrophic cardiomyopathy
Cardiac tumor

❑ Neurological diseases:

Parkinson's disease
Diabetic neuropathy

Metabolic disorders (diabetes) ❑ Recent trauma

Identify possible triggers:

Suggestive of reflex syncope
Emotional stress
❑ Crowded places (agoraphobia)
❑ Warm weather
❑ Prolonged standing
❑ Head motion
❑ Arm motion
❑ Shaving

Suggestive of cardiovascular or orthostatic hypotension
❑ Change in position

Examine the patient

Heart rate

❑ Irregular rhythm (suggestive of AF)
Tachycardia (suggestive of orthostatic hypotension, cardiovascular or reflex syncope)
Bradycardia (suggestive of cardiovascular syncope)

Blood pressure:

❑ Measure in both arms, while standing and supine
Orthostatic hypotension (Fall in systolic BP ≥ 20 mmHg and/or in diastolic BP of at least≥ 10 mmHg between the supine and sitting BP reading)
Hypertension (suggestive of cardiovascular syncope)

Respiratory rate

Tachypnea (suggestive of reflex syncope)

Rales (suggestive of HF)

Palpitations (suggestive of arrhythmia)
Carotid bruits (suggestive of cardiovascular syncope)

Aortic stenosis: crescendo-decrecendo systolic ejection murmur best heard at the upper right sternal border
Pulmonary stenosis: systolic ejection murmur best heard at the left second intercostal space

Heart sounds

❑ Loud P2 (suggestive of pulmonary hypertension)

Focal abnormalities (suggestive of stroke or cerebral mass)

Vision loss

Glasgow coma scale
❑ Signs suggestive of Parkinson's disease:

Postural instability
❑ Shuffling gait

Order labs and tests

EKG (most important initial test)

Myocardial infarction
Heart block
Long or short QT



Glucose (rule out hypoglycemia)

Hypocapnea (suggestive of tachypnea, rule out psychiatric disease)

Order imaging studies

Echocardiography in case of:

Structural heart disease
Myocardial infarction
Cardiac valve disease

Head CT in case of:

Head trauma

Confirm diagnosis of syncope

Must have this 3 characteristics:
❑ Short duration
❑ Rapid onset
❑ Complete spontaneous recovery

Diagnostic criteria


Arrhythmia and cardiac ischemia-related syncope is diagnosed by EKG specific findings (Class I; Level of Evidence: C)
❑ Cardiovascular syncope is diagnosed when syncope presents with structural heart disease (Class I; Level of Evidence: C)

Orthostatic hypotension (OH)

❑ Diagnosed when syncope occurs after standing up and there is documentation of OH. (Class I; Level of Evidence: C)


Vasovagal syncope: if is precipitated by emotional distress and is associated with typical prodrome. (Class I; Level of Evidence: C)
❑ Situational syncope: if occurs during or after specific triggers. (Class I; Level of Evidence: C)

Risk stratification

Determine if there are any high risk criteria:
❑ Severe structural heart disease
❑ Clinical or ECG features suggesting arrhythmic syncope:

Syncope during exertion or supine
Palpitations at the time of syncope
❑ Family history of SCD
❑ Non-sustained VT
❑ Conduction abnormalities with QRS >120 ms
Sinus bradycardia
❑ Pre-excited QRS complex
Long or short QT
Brugada pattern

❑ Important comorbidities:

❑ Severe anemia
Electrolyte disturbance

Consider additional tests

Stool guaiac test (rule out GI bleeding)
❑ Blood and urine toxicology tests (rule out intoxication)

Consider alternative diagnoses:

With loss of consciousness:

Coma (Glasgow coma scale < 8, profound state of unconsciousness)
Sudden cardiac arrest (absence of pulse)
Epilepsy (inquire past medical history)
❑ Findings: aura, prolonged confusion, muscle ache,
❑ Perform neurological evaluation (Class I; Level of Evidence: C)
❑ Perform tilt testing (Class IIb; Level of Evidence: C) , preferably with concurrent EEG and video monitoring if doubt of mimicking epilepsy
❑ Vertebrobasilar TIA

Without loss of consciousness:

❑ Drop attacks
❑ Functional /psychogenic pseudosyncope
❑ Perform a psychiatric evaluation (Class I; Level of Evidence: C).
TIA of carotid origin

❑ Immediate in-hospital monitoring (in bed or telemetry) to look for abnormalities suggestive of arrhythmic syncope (Class I; Level of Evidence: B).

Recurrent syncopes

Cardiac or neurally mediated tests as appropriate:
❑ Holter if > 1 episode/week (Class I; Level of Evidence: B).
External loop recorder (ELR) if interval between episodes < 4 weeks (Class IIa; Level of Evidence: B).
Carotid sinus massage in patients > 40 years with uncertain syncopal etiology (Class I; Level of Evidence: B).

Contraindicated in patients with previous TIA or stroke in the past 3 months.
Contraindicated in patients with carotid bruits.

Diagnostic criteria

❑ Induction of reflex hypotension or bradycardia with reproduction of syncope is diagnostic for reflex syncope (Class I; Level of Evidence: B).
❑ Induction of progressive orthostatic hypotension with or without symptoms is diagnostic for orthostatic hypotension (Class I; Level of Evidence: B).

DrugAdult dosage
Inhaled Short Acting β Agonists (SABA)
a) Nebulizer solution
b) MDI

♦ 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed or 10-15 mg/hour continuously.
♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
a) Nebulizer solution
b) MDI

♦ 1.25-2.5 mg every 20 mins for 3 doses, then 1.25-5 mg every 1-4 hours as needed.
♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Ipratropium bromide
a) Nebulizer solution
b) MDI

♦ 0.5 mg every 20 mins for 3 doses, then as needed.
♦ 8 puffs every 20 mins as needed for upto 3 hours.
Ipratropium with albuterol
a) Nebulizer solution (each 3 ml containing 0.5 mg ipratropium and 2.5 mg albuterol)
b) MDI (each puff contains 18 mcg ipratropium and 90 mcg albuterol)

♦ 3 ml every 20 mins for 3 doses, then as needed.
♦ 8 puffs every 20 mins as needed for 3 hours
Systemic corticosteroids
Prednisone/Prednisolone/Methylprednisolone ♦ 40-80 mg/day in 1 or 2 divided doses until peak expiratory flowrate (PEF) reaches 70% of personal best.

Clinical courseUnstable
Physical examination Signs of heart failure
Functional class IV
6MWD Less than 400 m
EchocardiogramRV Enlargement
HemodynamicsRAP high
CI low
TreatmentIntravenous prostacyclin and/or combination treatment
Frequency of evaluation Q 1 to Q 3 months
FC assessment Every clinic visit
6MWT Every clinic visit
Echocardiogram2Q 6 to Q 12 months/center dependent
BNPcenter dependent
RHCQ 6 to Q 12 months or clinical deterioration