Syncope: Things We Do For No Reason & Things We Do For Reason-Slides

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This 2024 SHM Converge presentation by Drs. Daniel Dressler and Romil Chadha focused on syncope evaluation, distinguishing between unnecessary tests (“Things We Do For No Reason”—TWDFNR) and justified diagnostics (“Things We Do For Right Reason”—TWDFRR). Key educational objectives included evaluating the usefulness of orthostatic vital signs, ECG, pulmonary embolism (PE) workup, neurological imaging (CT head, EEG), echocardiography, and tilt table testing in syncope patients.<br /><br />Syncope classifications per European and American guidelines identify neurally-mediated reflex syncope (~60-70%), orthostatic (~10%), and cardiac syncope (~10-20%) as the main types, with cerebrovascular causes considered rare.<br /><br />Initial syncope evaluation should always include detailed history, physical exam, and ECG, which together yield diagnoses in up to 88% of cases. Orthostatic vital sign measurements are underutilized (performed in only 27-38% of patients) despite their clinical significance in predicting symptoms, falls, and mortality. ECG is widely performed (>90% adherence) but contributes to diagnosis or management changes in only about 3-7% of cases.<br /><br />Regarding PE, recent studies (PESIT, BASEL IX) show that pulmonary embolism is present in approximately 2.5-4% of first-time syncope patients after structured workup. PE evaluation with Wells score and D-dimer is recommended selectively for high-risk patients, rather than routine imaging for all.<br /><br />Neurological testing (CT head, EEG, carotid ultrasound) has a low diagnostic yield (~1.5%) in syncope without focal neurological findings, and major guidelines advise against routine use of these unless neurological symptoms or exam abnormalities exist.<br /><br />Echocardiography rarely identifies actionable findings in syncope patients with normal history, physical exam, and ECG (~1% yield). It is recommended mainly in patients with abnormal cardiac exam or ECG.<br /><br />Tilt table testing helps diagnose neurally-mediated syncope when initial evaluation is inconclusive, especially in recurrent cases, but is not routinely indicated for all syncope patients. Its sensitivity improves with pharmacological provocation, and recent protocols have optimized testing duration and methods.<br /><br />In summary, syncope evaluation should prioritize orthostatic vitals and ECG universally. Pulmonary embolism workup is reserved for at-risk patients using clinical scores. Neuroimaging and routine echocardiography are unwarranted without relevant findings. Tilt table testing is a specialized tool for selected recurrent or unclear cases. This evidence-based approach minimizes unnecessary testing, reduces costs, and improves patient care.

Keywords

syncope evaluation

orthostatic vital signs

ECG in syncope

pulmonary embolism workup

neurological imaging in syncope

echocardiography in syncope

tilt table testing

neurally-mediated syncope

syncope guidelines

diagnostic yield in syncope