General: mental status, temperature, hydration status, pallor, or cyanosis.
Vital signs: tachycardia, bradycardia, irregularity, or orthostatic hypotension.
Cardiovascular: heart sounds, murmurs, bruits, edema, rales, and pulses.
Neurologic: cranial nerves, reflexes, strength and sensation, tremor, Romberg's sign, gait, and cerebellar signs
The most important single initial test to evaluate syncope is the ECG; it is easy and inexpensive and can quickly identify life-threatening arrhythmias or ischemia. Although the diagnostic yield is only 5%, if the ECG is normal, ischemia, arrhythmias, and organic heart disease are very unlikely. If the ECG is abnormal but does not clearly demonstrate a likely cause for syncope (complete heart block or runs of ventricular tachycardia, for example), other tests are needed to clarify the underlying problem that may be related to the syncope. The result of the ECG, therefore, helps to direct the course of further workup.
Holter monitor or telemetry performed for 24 hours. For patient with organic heart disease, this gives a diagnostic yield of from 2% for arrhythmias correlated to symptoms to 21% with unrelated arrhythmias. Extending this monitoring to 72 hours is not useful.
A loop event monitor is a portable, prolonged ambulatory event recorder indicating if there is recurrent syncope and no organic heart disease (yield = 24% to 47%).
This invasive cardiac monitoring and arrhythmia induction procedure gives a 50% diagnostic yield for those with organic heart disease or abnormal ECG (compared with 10% if no organic heart disease). This is considered the gold standard for arrhythmia diagnosis but it is expensive and invasive. Powerful predictors of a positive test are an ejection fraction less than 40%, bundle branch block, or atrial fibrillation.
Tilt table testing
Tilt table testing is indicated for unexplained, recurrent syncope when arrhythmia or organic heart disease is excluded and neurocardiogenic syncope is suspected. In this setting, the sensitivity is 67% to 83% and specificity is 90%.
Echocardiogram and stress
Echocardiogram and stress tests are used only to evaluate exertional symptoms (echo first in this case) or suspected organic heart disease.
Computed tomography scan is used to evaluate focal neurologic signs.
Electroencephalogram is indicated for seizure activity only.
Consider this if the patient is aged more than 60 years with unexplained syncope. Perform in the clinic if no bruits, ventricular tachycardia, recent stroke, or myocardial infarction.
Blood tests, including hematocrit, serum chemistries, and pregnancy test, are not for screening; order only if a specific medical condition is suspected.
Psychiatric evaluation is useful in the setting of a high recurrence rate in a young patient without resultant injuries and no evidence of organic heart disease.
5. Diagnostic assessment
The keys to the diagnosis of syncope are the history, physical examination, and ECG, yielding a diagnosis 45% of the time. The history and physical should focus on cardiac, neurologic, and medication-related issues. Directed testing can add 8% to diagnosis. Further classification by age and presence of organic heart disease can help focus evaluation and treatment. If organic heart disease is present or the ECG is abnormal, inpatient telemetry monitoring and electrophysiologic studies are recommended. If organic heart disease is not evident, ambulatory loop ECG and psychiatric evaluations are indicated, as well as possible tilt table testing.
Although most syncope patients can be evaluated in the outpatient setting, hospitalization is recommended for those with organic heart disease, chest pain, a history or suspicion of arrhythmia, or presence of neurologic symptoms or signs suggesting transient ischemic attack or stroke. The extent of severity of the organic heart disease is the key determinant of mortality and should direct evaluation and therapy. Despite extensive evaluation and testing, the diagnosis may still be elusive in approximately 40% of patients with recurrent syncope, but fortunately these patients have a low incidence of morbidity and mortality.
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