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Syncope Workup Basic Insights

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The syncope workup is the collective efforts of a physician(s) to determine the cause of a patient’s fainting spell(s).  There are official guidelines for what it should consist of based on both expert opinion and evidence-based medicine.  The various parts of the workup include the following:  

  • The history
  • The physical examination, including measurement of the blood pressure in a lying and upright position
  • An electrocardiogram
  • Laboratory tests if indicated
  • X-ray studies if indicated
  • Test procedures if indicated  

The completion of the evaluation process is usually not in one day or in one sitting.  Its time span might be up to several days.  syncope workupThe history, physical examination, an orthostatic blood pressure check and an EKG are fairly standard for all patients presenting with a faint or near faint. But the other aspects of the syncope workup depend on the index of suspicion of the doctor(s) doing the evaluating.  The same is true in the case of presyncope. The thought process takes into account the likelihood of both the mechanism and the actual cause of a patient’s faint.  

The history is the most important part of the workup because it tends to suggest a diagnosis in up to 50% of patients. Key aspects of it should focus on: confirming that syncope is in fact the cause of a person’s loss of consciousness; establishing or ruling out a history of cardiovascular disease; and unveiling facts that might point to the actual cause of the faint.  The latter might include symptoms preceding the faint; medications used; and a family history of sudden death or heart disease.   

A proper history can also help differentiate between syncope and other causes of loss of consciousness.  Some of the more common ones it can exclude are a seizure, a sudden drop in blood glucose, a transient ischemic attack and a concussion.  

There are three main types of syncope based on the mechanism.  They are the following:

When the index of suspicion for neurally mediated syncope is high, a tilt table test is often in order.  Not only does it help confirm the diagnosis if it results in a drop in the blood pressure (BP) and a decrease in the heart rate.  It also helps to rule out orthostatic hypotension syncope, in which case it causes a drop in the BP with an increase in the heart rate. There are other provocative tests for evaluating suspected neurally mediated syncope, but a discussion of them is beyond the scope of this post.   

Evaluation of syncope often requires hospitalization if there is a strong suspicion of a cardiac cause, particularly an arrhythmia.  The workup should include heart monitoring.  Such monitoring will oftentimes yield a diagnosis during the hospitalization.  But if not, heart monitoring outside of the hospital might be required.  The most basic heart monitoring outside of the hospital is with a Holter monitor, but the duration of the recording is usually limited to up to 72 hours, which might fail to detect sporadic and infrequent arrhythmias.  Thus, more prolonged monitoring is often necessary.  Thanks to the external loop recorders and implantable loop recorders, longer monitoring is now possible. The net effect is a greater diagnostic yield.   

A standardized approach in evaluating patients with syncope has many advantages.  It reduces costs by decreasing admissions to the hospital and limiting the number and types of tests performed.  It increases the accuracy and promptness of diagnosis.  It promotes prompt treatment.  It also often prevents premature death.  

The physician is the chief orchestrator and purveyor of these benefits.  But the patient also has a role.  It is prompt presentation to a doctor for a well-timed syncope workup and the providing of him or her with the most useful and accurate information possible. The end result of the best mutual efforts is often better patient outcomes.   

The value of a proper syncope workup is an example of the importance of patient engagement, not only in treatment of illness, but also in the evaluation of it.

 

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