APPROACH TO SYNCOPE

Dr. Faisal Boker

Supervised by Dr. Maan Jamjoom
 TO BE FIXED

• Fix references all over

• Visibility: Change colors to improve contrast, Replace numbers in LH nomograms
CLINICAL APPROACH
 OUTLINE
• Case
• Definition
• Epidemiology
• Pathophysiology and Differential Diagnoses
• History and Physical examination
• Investigations and Monitoring
• Clinical approach (Flowchart)
• Clinical decision tools
• Disposition
 CASE
A 27 year old was brought to the ER after an episode of loss of consciousness that
occurred a few hours ago. It lasted for a few seconds. The event was witnessed by his
wife, who said he had jerky movements in his upper and lower limbs.
He came to the ER walking, looking well.

How to approach this case?

• General look and Vitals.
• History and physical examination: Was this syncope, seizure or something else?
 WHAT IS SYNCOPE?
• “Sudden transient loss of consciousness with a loss of postural tone” (1)
• Transient episode ➔ the cause of CNS dysfunction should be transient.
• Persistent causes of significant CNS dysfunction ➔ result in coma or depressed consciousness

• “A symptom complex consisting of a brief loss of consciousness associated with an

inability to maintain postural tone that spontaneously resolves without medical
intervention with the person returning to their baseline neurologic condition” (2)
• Diagnostic approach for presyncope = syncope
…Why is recognizing it important to us?

1. Walls R, Hockberger R, Gausche-Hill M. Rosen's emergency medicine-concepts and clinical

practice. Elsevier Health Sciences; 2018.
2. Tintinalli JE. Emergency medicine: a comprehensive study guide. McGraw-Hill Education; 2020.
 EPIDEMIOLOGY OF SYNCOPE
• Accounts for 3% of ER visits α
• Most causes of syncope are benign and have favorable outcomes.
• 7.6% death rate (1 year within syncopal episode): **
• 1/3 of those -in patients with a cardiac history- are cardiac related deaths
• Key predictors of mortality Include: Age, CHF and CAD

• The most common causes of syncope identified in the Framingham Heart Study* were:
• Vasovagal/Reflex (21%) ➔ No increased risk of morbidity or mortality α
• Cardiac (10%) ➔ Doubles the risk of Death*
• Orthostatic (9%) ➔ No increased risk of morbidity or mortality
• Medication (7%) ➔ No increased risk of morbidity or mortality
• Neurologic (4%), ➔ ↑ risk of Death by 50%*
• Unknown (37%). ➔ ↑ risk of Death by 30%*

• Recurrence of syncope may be as high as 50%. Β

*Sumner GL, Rose MS, Koshman ML, Ritchie D, Sheldon RS, Prevention of Syncope Trial Investigators. Recent history of vasovagal syncope in a young, referral‐based
population is a stronger predictor of recurrent syncope than lifetime syncope burden. Journal of cardiovascular electrophysiology. 2010 Dec;21(12):1375-80.

α Rosen Β Tintinalli ** Kessler C, Tristano J, De Lorenzo RA: The emergency department approach to syncope: evidence-based guidelines and prediction rules. Emerg Med
Clin North Am 28:487–500, 2010.
SYNCOPENarcolepsy
3. CNS Dysfunction with
Hypoglycemia

PATHOPHYSIOLOGY
Psychogenic Normal Cerebral Hypoxemia
& DIFFERENTIAL Perfusion
Toxic: CO, Drugs Seizure

Impaired Function of
2. Focal 1. Systemic
Brainstem
Hypoperfusion or Both Hemispheres Hypotension
Hypovolemia/Hemorrhage
Orthostatic Mediated Orthostatic
Autonomic Failure
Syncopal Episode: Mediated
LOC + Drug Induced
Subclavian Steal Loss of postural tone

Hyperventilation Reflex (Vasovagal) Neurally

Valvular Stenosis Situational Mediated
CVD HCM
Outflow Obstruction
PE
SAH Tamponade
See “ECG” section ↓CO: Tachy/Brady Cardiovascular
Basilar Artery Migraine Aortic Dissection
Other
Myocardial Infarction
 DIAGNOSTIC GOALS

• Distinguish true syncope from syncope mimics

• To assess the risk of a cardiac cause or sudden cardiac death
• To determine the cause of syncope to initiate treatment/prevention.
 HISTORY OF SYNCOPE

• Ask witnesses to supplement Hx

• Obtain details regarding; (Think Chronologically)
• Past medical Hx (Mainly Heart disease; dysrhythmia, structural heart disease, CHF)
• Precipitating factors (What was the patient doing?)
• Sx prior to the episode
• Sx during the episode
• Sx after the episode

• Our first goal is to determine: Did this patient have a cardiac syncope?
 HISTORY OF SYNCOPE

• With many Sx and Signs to ask about, why not…. Be evidence based in Hx?
HISTORY AND PHYSICAL EXAMINATION
 HISTORY OF SYNCOPE
Did this patient have a cardiac syncope?

Patient Demographics/Past medical LR+ LR-

• Atrial fibrillation or flutter 7.3 0.89
• Severe structural heart disease 4.05 0.68
• History of heart failure 3.05 0.58
• Age at first syncopal spell > 35 3.3 0.13
 HISTORY OF SYNCOPE
Did this patient have a cardiac syncope?

Patient Demographics/Past medical LR+ LR-

+
• Atrial fibrillation or flutter 7.3 0.89
• Severe structural heart disease 4.05 0.68 -

• History of heart failure 3.05 0.58

• Age at first syncopal spell > 35 3.3 0.13

*Averages of ranges
 HISTORY OF SYNCOPE
Did this patient have a cardiac syncope?

Patient Demographics/Past medical LR+ LR-

• Atrial fibrillation or flutter 7.3 0.89 +
• Severe structural heart disease 4.05 0.68
• History of heart failure 3.05 0.58 -
• Age at first syncopal spell > 35 3.3 0.13

*Averages of ranges
 HISTORY OF SYNCOPE
Did this patient have a cardiac syncope?

Precipitating/Predisposing factors LR+ LR-

• During effort 1.4-15 0.92
• While Supine 1.1-4.9 0.95

• After using the toilet 0.05 1.1

• Pain/Medical procedure 0.12 1.8
• Warm place 0.17 2.0
• Stress 0.28 1.1
• Prolonged Sitting/ Standing 0.54 2
 HISTORY OF SYNCOPE
Did this patient have a cardiac syncope?

Precipitating/Predisposing factors LR+ LR-

• During effort 1.4-15 0.92
• While Supine 1.1-4.9 0.95 -

• After using the toilet 0.05 1.1

+
• Pain/Medical procedure 0.12 1.8
• Warm place 0.17 2.0
• Stress 0.28 1.1
• Prolonged Sitting/ Standing 0.54 2
 HISTORY OF SYNCOPE
Did this patient have a cardiac syncope?

Symptoms Prior to the Episode LR+ LR-

• Dyspnea 3.5 0.87
• Chest pain/angina 3.6 0.76
• Palpitations 1.9 0.94
• Absence of prodromes 1.6 0.79

• Diaphoresis 0.49 1.2

Intuitively cardiac/atypical ACS presentation!
• Nausea 0.44 1.1
 HISTORY OF SYNCOPE
Did this patient have a cardiac syncope?

Symptoms Prior to the Episode LR+ LR-

• Mood changes 0.09 1.3
• Feeling cold 0.16 1.1
• Headache* 0.17 1.2

• Abdominal discomfort 0.3 1.1

• Numbness or Tingling 0.33 1.3
• Lightheadedness 0.38 1.2

*Just because it’s not cardiac, doesn’t mean it is always benign…

 HISTORY OF SYNCOPE
Did this patient have a cardiac syncope?

During and After the Episode LR+ LR-

• Cyanotic during syncope 6.2 0.93

• Injury 1.2 1.1

• Mood changes 0.21 1.2

• Nausea 0.34 1.3
• Numbness or tingling 0.31 1.2
 PHYSICAL EXAMINATION

Focus -in all syncope patients- primarily on

• Cardiovascular system; vitals (including BSL)
• Neurologic system

Based on Suspicion/DDx, e.g. if you suspect…

• Orthostatic hypotension ➔ Orthostatic Vitals and signs
• Carotid Sinus Hypersensitivity ➔ Carotid massage
• GI Bleed / Anemia ➔ Rectal examination for gross blood
PHYSICAL EXAMINATION

Echo/US
 BACK TO OUR CASE
A 27 year old was brought to the ER after an episode of loss of consciousness that
occurred a few hours ago. It lasted for a few seconds. The event was witnessed by his
wife, who said he had jerky movements in his upper and lower limbs.
He came to the ER walking, looking well.
 BACK TO OUR CASE
What would you like to ask?
27 y/o, Medically and surgically free.
Precipitating factors: was lying down on bed
No emotional upset, stress
Pre event: Palpitations, SOB,
No lightheadedness, Neuro Sx/headache or abdominal discomfort.
Event: He can’t recall anything…
His wife: The episode lasted less than 30 seconds, a few upper and lower limb
jerky movements. No cyanosis.
Post event: Woke up completely fine, no Neurological deficit or Sx, No N/V, no fatigue/post ictal
Other: No change in medications, No Family Hx of sudden cardiac death.
What would you like to examine?
• CVS and Neurological exam were normal
What next…? What investigations will you order for this patient?
 ANCILLARY STUDIES
What Labs/Investigations would you order in Syncope?
• 12-Lead ECG
• When is it warranted?

• Routine hematologic and urine studies are generally not indicated. (Low yields)
• So based on your Hx and PE, + to exclude uncommon causes e.g.
• Dysrhythmia ➔ Outpatient Holter or prolonged ECG monitoring
• ICH (Headache/FND) ➔ Brain CT
• HF ➔ Chest X-ray, Bedside pulmo US, ± BNP
OUTPATIENT OR INPATIENT TESTS
 ECG IN SYNCOPE

1. Be systematic
2. Pattern Recognition (WOBBLERR)
 ECG IN SYNCOPE

1. Be systematic
• Rate and rhythm, looking for AV blocks and Dysrhythmias
• Axis ➔ RBBB or hemiblocks
• QRS and ST segment morphology:
• Looking for delta waves/Preexcitation
• ST segment and T wave changes suggestive of Brugada, MI, or PE,
• Checking again for bundle branch morphologies

• Intervals, including PR intervals (shortening) and QTc intervals (prolongation).

 ECG IN SYNCOPE

2. Pattern Recognition (WOBBLERR) (after excluding obvious ischemia/dysrhythmia)

• Wolff-Parkinson-White
• Obstructed AV pathway (AV blocks)
• Bifascicular Block
• Brugada pattern
• Left ventricular hypertrophy (Aortic stenosis, HOCM)
• Epsilon Wave
• Right Ventricular Strain (PE)
• Repolarization abnormality (Short or Prolonged QT)
 WOLFF-PARKINSON-WHITE

• Short PR <120 ms and delta wave Type A pattern: Dominant R wave in V1 (Lt sided)
• QRS >120 ms [Link]
 WOLFF-PARKINSON-WHITE

• Short PR <120 ms and delta wave Type B pattern: Dominant S wave in V1 (Tt sided)
• QRS >120 ms [Link]
OBSTRUCTED AV PATHWAY (AV BLOCKS)

[Link]
 BIFASCICULAR BLOCK

Left Axis Deviation + rS complex in inferior leads ➔ Left anterior fascicular block
rsR’ “Bunny ear” in V1-V3 + Slurred S wave in I, aVL, V5, V6 ➔ RBBB
Left anterior fascicular block + RBBB ➔ Bifascicular block
 BRUGADA PATTERN

• Type I: Coved ST segment elevation continuing into a T wave inversion.

 LEFT VENTRICULAR HYPERTROPHY
(AORTIC STENOSIS, HOCM)

•Markedly ↑ LV voltages: huge precordial R and S waves that overlap with the adjacent leads (SV2 + RV6 >> 35 mm).
•R-wave peak time > 50 ms in V5-6 with associated QRS broadening
 EPSILON WAVE
(ARRHYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA)

[Link]
 RIGHT VENTRICULAR STRAIN (PE)

T-wave inversions are seen in the right precordial (V1-4) and inferior leads (III, aVF)
Most common abnormality w/ PE is Sinus Tachy
Other changes include S1Q3T3, RAD, P pulmonale, non-specific ST segment and T wave changes.
[Link]
 PE AMONG SYNCOPE PATIENTS
• A study in 2018 by P Prandoni et al, claimed that 1
• Among syncope patients; The prevalence of PE was 17.3%
• ” Pulmonary embolism was identified in nearly one of every six patients hospitalized
for a first episode of syncope.”
• Had numerous significant biases and limitations; 2 There is a high prevalence of PE among high-
risk first time syncope patients that are hospitalized.

• Many studies, including one by Thiruganasambandamoorthy V et al, (N=4,739) 3

• Overall the prevalence of PE was 0.3% among all ED patients with syncope; and a 0.9% among
those hospitalized for syncope

• Conclusion: PE investigation shouldn’t be routine, but guided based on Hx, PE and RFs.

1. Prandoni P, Lensing AW, Prins MH, Ciammaichella M, Perlati M, Mumoli N, Bucherini E, Visonà A, Bova C, Imberti D, Campostrini S. Prevalence of
pulmonary embolism among patients hospitalized for syncope. New England Journal of Medicine. 2016 Oct 20;375(16):1524-31.
2. [Link]
3. Thiruganasambandamoorthy V et al. Prevalence of Pulmonary Embolism Among Emergency Department Patients with Syncope: A Multicenter Prospective
Cohort Study. Ann Emerg Med 2019. PMID: 30691921
 REPOLARIZATION ABNORMALITY
(SHORT OR PROLONGED QT)

[Link]
 WPW Type A
BACK TO OUR CASE AGAIN

What if it weren’t so clearly cardiac?

CLINICAL APPROACH
CLINICAL APPROACH
 CLINICAL DECISION MAKING TOOLS:

Clinical decision making tools:

• San Francisco Syncope Rule
• EGSYS Score
• Canadian Syncope Risk Score
• FAINT Score

• Calgary Vasovagal score

 SAN FRANCISCO SYNCOPE RULE

• Predicts risk for serious outcomes* at 7 days in patients presenting with syncope or
near-syncope
• Stratifies patients into: “Low risk”, or “Not Low risk”

*defined as death, MI, arrythmia, PE, stroke, SAH, significant hemorrhage, or any condition causing a
return ED visit and hospitalization for a related event.
 SAN FRANCISCO SYNCOPE RULE

CHESS
• C: History of Congestive Heart Failure.
• H: Hematocrit < 30%
• E: Abnormal ECG: Not sinus OR New changes
• S: Shortness of breath
• S: Triage Systolic blood pressure < 90
 SAN FRANCISCO SYNCOPE RULE

Caveats
Normal Pt
• Can it really rule it out? (1) (Based on external validation, meta-analysis)
• Sensitivity = 86% Specificity = 49% +
• +ve LH = 1.69 -ve LH = 0.29 High Risk Pt
-
• Gestalt > SFSR in ruling out high risk
• Gestalt is 100% sensitive (But only 30% specific)(2)

• ECG is prone to subjective interpretation

• The most commonly missed outcome was
cardiac dysrhythmia

1 meta analysis published in AEM

 EGSYS SCORE

• Predicts the likelihood that syncope is from a cardiac cause

• Validated in Omar albassam’s and in Thiruganasambandamoorthy’s studies
• A EGSYS score ≥3 had a
• Sensitivity = 90% Specificity = 71%
• +ve LH = 2.8-3.3 -ve LH = 0.12-0.17

INSERT REFERENCE HERE

 EGSYS SCORE

INSERT REFERENCE HERE

 CANADIAN SYNCOPE RISK SCORE
• Predicts 30-day serious adverse events in patients presenting with syncope
• Derived by Dr. Venkatesh Thiruganasambandamoorthy et al’s study

*defined as Death, arrhythmia, myocardial infarction, serious structural heart disease, aortic dissection,
pulmonary embolism, severe pulmonary hypertension, severe hemorrhage, subarachnoid hemorrhage,
or any other serious condition causing syncope and procedural interventions for the treatment of
syncope.
CANADIAN SYNCOPE RISK SCORE

No need for cardiac workup

Should undergo further investigation for

cardiac and non-cardiac causes of syncope

Has been internally validated, but no prospective

external validation has been published yet.
 FAINT SCORE

• Risk-stratification tool to predict 30-day death or serious cardiac outcomes* in

syncope patients aged ≥ 60
• Derived in a 10/2019 article by Probst MA et al (N=3,177)
• Meant to help rule out serious syncope
• Not externally validated yet.

* Serious cardiac outcomes included significant cardiac arrhythmia, myocardial infarction, new diagnosis of
significant structural heart disease, or cardiac intervention.
 CALGARY VASOVAGAL SCORE

• Diagnosis of vasovagal syncope

• Vasovagal if the score is ≥-2
sensitivity = 89% specificity = 91%**

• For predicting cardiac (Score >-2):*

+ve LH = 1.7-8.6 -ve LH = 0.1-0.84

Albassam*
Albassam 25**
 DISPOSITION

• Critical Diagnosis
➔ Stabilize in ED then ➔ Admission to ICU or other inpatient unit
• Emergent Dx or worrisome Sx (Chest pain, unexplained SOB, worrisome ECG findings )
➔ Admission for further workup and observation
• Undiagnosed but w/worrisome presentation; Pre-existing HD, CHD, comorbid, exertional syncope
➔ Consider observation and make use of clinical decision tools
• Non-emergent Dx
➔ Discharge w/ follow up in Primary health care setting
Esp. Young patients (<45 M, <55 F) without any worrisome Sx or ECG findings
 REFERENCES

• 1. Serrano LA, Hess EP, Bellolio MF, Murad MH, Montori VM, Erwin PJ, et al.
Accuracy and quality of clinical decision rules for syncope in the emergency
department: a systematic review and meta-analysis. Annals of emergency medicine.
2010;56(4):362-73. e1.
• 2. Sun BC, Mangione CM, Merchant G, Weiss T, Shlamovitz GZ, Zargaraff G, et al.
External validation of the San Francisco syncope rule. Annals of emergency
medicine. 2007;49(4):420-7. e4.