SHM's Clinical Quick Talks-Syncope

Pdf Summary
A 66-year-old male is brought to the emergency department after fainting at a restaurant. He had complained of nausea and stood up to go to the restroom but immediately fell back and lost consciousness for about a minute. He has a history of hypertension, hyperlipidemia, and depression. He was briefly admitted to the hospital three years ago for chest pain but was told he didn't have a heart problem. <br /><br />The best next step for this patient is to discharge him home with referrals for an outpatient echo and Holter monitor. This is because syncope, or transient loss of consciousness, can have various causes and further testing is needed to determine the underlying cause. The three main mechanisms explaining syncope are neural-mediated (vasovagal), orthostatic hypotension, and cardiac. All of these result in transient global cerebral hypoperfusion. <br /><br />Diagnostic workup for syncope involves differentiating it from other causes of loss of consciousness and determining the type or etiology of syncope. A thorough history and physical exam are important, along with various diagnostic tests. These tests include carotid sinus massage, tilt testing, ECG, telemetry monitoring, Holter monitoring, stress testing, echocardiogram, and neurologic tests such as EEG and imaging studies. <br /><br />Risk stratification is also important for determining further management and treatment. Multiple risk stratification tools are available, including the EGSYS score, which predicts a cardiac etiology for syncope and mortality. Certain ECG abnormalities, such as sinus bradycardia, AV blocks, ventricular tachyarrhythmias, and Q wave changes consistent with ischemic heart disease, can also provide important information for risk stratification. <br /><br />Treatment for syncope depends on the underlying cause or mechanism. For vasovagal syncope, reassurance and education are important. For orthostatic hypotension, lifestyle modifications and increased awareness can improve safety. Cardiac syncope may require specific treatments such as pacemakers or medication. <br /><br />In the case of this patient, further management decisions can be made after obtaining an ECG. Since vasovagal syncope is the most likely diagnosis based on the patient's history and lack of signs of structural heart disease, option 4, discharge home with referrals for outpatient echo and Holter monitor, is the best next step.
Asset Subtitle
Remus Popa
Meta Tag
Core Competency Asthma
Format Study Guide
Keywords
66-year-old male
emergency department
fainting
nausea
syncope
underlying cause
diagnostic workup
risk stratification
treatment
ECG