Rapid Clinical Updates: Syncope Simplified-Handout

Handout

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Syncope is a frequent cause for hospital admission, often leading to excessive testing and increased healthcare costs. High-value care focuses on testing that influences management decisions, emphasizing the importance of a thorough history. Avoid routine admission for low-risk patients, unnecessary lab tests, cardiac imaging, carotid imaging, EEG without neurologic signs, and neuroimaging without focal neurological deficits or head trauma.<br /><br />The 2018 European Society of Cardiology (ESC) guidelines outline distinguishing high- and low-risk syncope features, diagnostic criteria for reflex syncope, orthostatic hypotension, and cardiac syncope. EKG and orthostatic vital signs are high-yield diagnostic tools in both emergency and inpatient settings, influencing management in about 25% of admitted cases. Point-of-care ultrasound (POCUS) can help evaluate serious conditions like aortic dissection, pericardial effusion, aortic stenosis, and cardiomyopathy.<br /><br />EKG is a low-cost, high-value tool; clinicians should be familiar with concerning abnormalities linked to syncope, such as conduction blocks, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, Brugada syndrome, long QT syndrome, and arrhythmogenic right ventricular cardiomyopathy. Note that EKG changes may be transient.<br /><br />Pulmonary embolism (PE) is an uncommon cause of syncope (0.06%-2.1% prevalence depending on setting). PE should be considered after ruling out other etiologies, using risk stratification tools like the Wells score and D-dimer testing.<br /><br />Many risk scores exist for predicting adverse outcomes in syncope, but most have limited accuracy and high sensitivity. The Canadian Syncope Risk Score may offer better performance but does not exceed clinical judgment. <br /><br />In summary, effective syncope management in ER and inpatient settings relies on focused clinical evaluation, selective testing guided by risk, and adherence to established guidelines to avoid unnecessary interventions and optimize patient care.

Keywords

Syncope

Hospital admission

High-value care

European Society of Cardiology guidelines

EKG abnormalities

Point-of-care ultrasound (POCUS)

Pulmonary embolism

Risk stratification

Canadian Syncope Risk Score

Selective testing