Patients that present with syncope can be challenging purely because syncope is a symptom, not a diagnosis.
We need to find the cause. The most important causes to look for are CARDIAC. Why? Because cardiac syncope is an independent predictor of overall mortality and cardiac mortality.
The cardiac causes include:
- Arrhythmias: ventricular and supraventricular
- Low flow states: cardiomyopathy, left ventricular failure
- Outflow Obstruction: valve abnormality
Don’t worry if it’s vasovagal, this is benign.
Don’t worry so much about TIA causing it. Only a posterior circulation TIA concerns me.
Remember that when you have thought about all these things, that you also think about the other causes of syncope that present in 10-15% of cases. These include:
- subarachnoid haemorrhage
- pulmonary embolism
- thoracic aortic dissection
- abdominal aortic aneurysm
Be afraid.
My approach is simple. I ask 4 questions:
- Is it a FIT or a FAINT?
- Is it a TIA?
- Is it CARDIAC?
- Is it one of those OTHER things I need to remember?
History is paramount. Examination is important and should include at minimum, a cardiovascular examination looking for murmurs and heart failure. Abdominal palpation and a per rectal examination as indicated depending on the history and a full neurological examination is important.
What about investigations? They should be guided by your history and examination and EVERYONE, EVERYONE, EVERYONE, should have an ECG!
Join me this year at the Annual Scientific Meeting of the Australasian College for Emergency Medicine this year, where I talk on this topic.
