Rapid Clinical Updates: Syncope Simplified-Slides

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The "Syncope Simplified" presentation, moderated by Dr. Lily Ackermann and featuring experts Dr. Carrie Herzke and Dr. Lauren Westafer, addresses syncope evaluation and management. Syncope—a transient loss of consciousness—is a common clinical challenge, accounting for 3% of ER visits, up to 6% of hospitalizations, and costing billions annually in the U.S.

Key points include:

1. <strong>Diagnosis Essentials:</strong> Confirm syncope versus mimics like seizures or trauma through history, physical exam, ECG, and selective labs based on risk factors. Important diagnoses to consider include reflex, orthostatic, cardiac causes (e.g., arrhythmias, structural heart disease), hemorrhage/anemia, intracranial hemorrhage, and pulmonary embolism.

2. <strong>Electrocardiogram (ECG):</strong> A critical early test to detect arrhythmias and cardiac structural problems, though ECG changes can be transient. Point-of-Care Ultrasound (POCUS) and targeted imaging are used if indicated.

3. <strong>Risk Stratification:</strong> While multiple syncope risk scores exist (San Francisco, Canadian Syncope Risk Score (CSRS), OESIL, Rose), external validation showed mixed accuracy. European guidelines advise against sole reliance on scores, favoring clinical judgment. The CSRS, however, shows promise in identifying serious 30-day adverse outcomes and potentially reducing unnecessary admissions.

4. <strong>Guidelines and Recommendations:</strong> The 2017 ACC/AHA/HRS and 2018 ESC guidelines emphasize thorough history, ECG, and risk assessment but caution against routine comprehensive labs, cardiac imaging, carotid Dopplers, EEG, or brain imaging unless specific neurological concerns exist.

5. <strong>Testing Yield and Costs:</strong> Orthostatic vital signs are a valuable, low-cost test underused in syncope evaluation. Extensive testing often adds cost without improving diagnosis. Imaging for pulmonary embolism is rarely needed unless suspicious clinical features or positive D-dimer exist.

6. <strong>Outcomes and Age:</strong> Causes differ by age, with neurally mediated syncope common even in older patients with heart disease. Clinical gestalt remains key in management decisions.

In conclusion, effective syncope evaluation prioritizes careful history and physical exam, ECG, and orthostatic vitals while limiting unnecessary tests and hospitalizations. The Canadian Syncope Risk Score may aid decision-making but cannot replace clinical judgment. This approach aims to balance patient safety with healthcare resource utilization.

References and disclosures confirm no conflicts of interest in the presentation content.
Keywords
syncope
transient loss of consciousness
syncope evaluation
ECG
risk stratification
Canadian Syncope Risk Score
orthostatic vital signs
cardiac arrhythmias
clinical judgment
syncope guidelines