SHM's Clinical Quick Talks-High Value Care: Syncope

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This document outlines an approach to evaluating syncope (fainting), updated March 2026. Initial assessment for all patients should include a focused history and physical, a complete neurological and cardiovascular exam, an electrocardiogram (ECG), and orthostatic vital signs.<br /><br />If there are no red flags, the syncope is most consistent with either reflex (vasovagal) syncope or orthostatic syncope. Reflex syncope is commonly triggered by emotional stress, pain, prolonged standing, or dehydration. Orthostatic syncope is associated with older age and conditions such as diabetes and Parkinson disease, as well as volume depletion and antihypertensive medications; it is supported by positive orthostatic vital signs. A clinical pearl notes that orthostatic vitals may be negative after volume resuscitation, even if orthostasis was the cause. In patients without red flags, no further testing is necessary.<br /><br />If cardiovascular red flags are present, the document emphasizes higher-risk “cardiovascular syncope.” Concerning features include known structural heart disease, prior myocardial infarction, active chest pain, heart failure, family history of sudden cardiac death, exertional syncope, syncope while seated, and abnormal cardiovascular examination or ECG. Suggested additional testing includes troponins, brain natriuretic peptide (BNP), echocardiography, ischemic evaluation, ambulatory cardiac monitoring, and D-dimer. Another clinical pearl highlights that pulmonary embolism may account for syncope in up to 25% of patients with a first syncope episode when no other clear cause is found.<br /><br />If cerebrovascular red flags are present, concern shifts to cerebrovascular syncope, suggested by an abnormal neurological exam or known carotid or vertebral artery stenosis. Recommended further evaluation includes CT head, CT angiography of the head and neck, and MRI brain.

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Michael LaLoggia, Mahir Qureshi, Nicholas Young

Meta Tag

Concept Syncope

Concept Cardiovascular Red Flags

Concept Cerebrovascular Red Flags

Concept Vasovagal Syncope

Concept Orthostatic Syncope

Keywords

syncope evaluation

fainting workup

initial assessment history and physical

ECG electrocardiogram

orthostatic vital signs

reflex vasovagal syncope

orthostatic hypotension syncope

cardiovascular red flags

ambulatory cardiac monitoring

cerebrovascular syncope imaging

Syncope

Cardiovascular Red Flags

Cerebrovascular Red Flags

Vasovagal Syncope

Orthostatic Syncope