This document discusses syncope (fainting), including: - Causes of syncope include vasovagal (50%), orthostatic hypotension (7%), and cardiac causes (7%). - Tests for syncope include ECG, echocardiogram, extended ECG monitoring, and tilt table testing. However, a good history is usually most useful and accurate. - Risk of adverse outcomes from syncope within 30 days includes mortality of 0.7% and other outcomes in 4.5% of patients. Structural heart disease is a risk factor.

1. Syncope
Fainting within the first 20 seconds of arising from lying or
sitting almost always have orthostatic hypotension
 1%-2% of emergency
 30%-50% of 1-2% are admitted
 Most common is vasovagal syncope-50%
 orthostatic hypotension -7%
 Cardiac syncope -7%
 Structural heart disease - 3%
 The 30-day mortality - 0.7%,
 30-day adverse outcome-4.5%

2. Define
• Syncope
– transient
– loss of consciousness
– rapid onset
– short duration,
– spontaneous recovery,
– associated with at least 1 of
– (1) Specific forms of syncope (like vasovagal syncope); and/or
– (2) the absence of features suggesting another cause of loss of consciousness
(like epileptic convulsions or hypoglycemia).

3. Aim
 Structural substrate ?
 Risk factors?
 Syncope spell detail?
 Induce syncope under controlled conditions(Tilt table)

4. Tests
Beyond an electrocardiogram are not usually needed
The most commonly used tests
 implantable loop recorders-30-40% diagnosis in 2-3 yrs
Tilt table testing
 Neither are needed most of the time
 A good history provides more useful and more accurate information in most

5. History
• 4 distinct phases
(1) the context before symptoms;
(2) prodromal symptoms
(3) how the patient felt afterward
(4)Try to get a bystander
• Vasovagal syncope and orthostatic vs from arrhythmic
• Strenuous exertion –Arrhythmias

6. Physical Examination
• No physical findings are completely diagnostic of syncope or its
causes
– aortic stenosis
– hypertrophic cardiomyopathy
– dilated left ventricle
– carotid sinus supersenistivity,
– orthostatic hypotension.

7. High risk markers for syncope

8. Future syncope

9. Risk score

10. Diagnostic Tests
• Positive - 1%-4%

11. 12-lead ECG
• Low detection
• Inexpensive
• Detects
– Conduction disease
– repolarization abnormalities
– QT prolongation/abbreviation,
– ischemic heart disease
– ventricular hypertrophy
– Brugada, ARVD
– Cardiomyopathy
–

12. ECG monitoring
• Arrhythmic
• Low detection rate
• Telemetry
– Structural heart disease
– High risk of arrhythmic events
– 72-hour :16%
– 1 month -12%
• Loop recorders : 30%-40% of patients are detected over 2-3
years.

13. Echocardiography
• Structural heart disease.

14. Tilt Table test
• The most common provocative test
• The goal is to trigger clinically reminiscent presyncope or
syncope
• Result of hypotension or bradycardia or both

15. To avoid syncope during MRI