History
• Yield 45-50%• Position of the patient• Precipitating factors• Presyncopal
symptoms• Syncope detail• Duration of attack• Post syncopal
symptom
• Associated symptoms– Chest pain
– Dyspnea
– Low back pain
– Palpitation
– Headache
• Medical history• Medicine history
Physical examination
• Vital signs– Pulse in both arm– BP, Postural BP– Temp
• Carotid massage• Cardiological examination• Neurological examination• External injury signs
Carotid massage
• Position supine and repeat in sitting and standing if negative in vasodepressor type
• Duration of massage 6-10sec• 15 sec difference between one to other side• ECG and BP monitoring• Complication
– Prolonged a systole– Ventricular fibrillation– Transient or permanent neurologic deficit– Sudden death
Investigation
• Blood – Blood glucose level
– Hb, PCV
– Electrolyte
– Cardiac enzyme
• Electrophysiology– ECG
– Holter monitoring
– Electrophysiological studies
– EEG
• Imaging– Chest X ray
– CT; brain, Chest ,abdominal
– Brain MR/MRI
– Ventilation perfusion scan
• Tilt table test
• Stress test
• Echocardiography
Blood Tests
• Yield 2-3%• Routine use is not recommended• Only if they are specifically suggested by the
results of the history or physical examination. • Pregnancy testing should be considered in
women of child-bearing age, especially those for whom tilt-table or electro physiologic testing is being considered
ECG
• Yield 5%
• Associated finding : 50%– Bundle branch block– Bifascicular block– Old MI– Ventricular Hypertrophy
• Cost effective investigation
Stress ECG
• Low yield 1%
• Indication– For exercise induced arrhythmias– Exertional syncope– Ischemia
Signal averaged ECG
• High sensitivity and specificity
• Inducible sustained ventricular tachycardia
• When CAD and VT is suspected
• As screening test for EP study
Prolonged ECG
• Yield Low– For 12 hour monitoring
– 4% symptomatic arrhythmias
– 17% no arrhythmia with symptoms
– 80% had a symptomatic arrhythmias
– 24 hour -> 14.7%
– 48 hours -> 11.1%
– 72 hours-> 4.2%
• Indication– Arrhythmic syncope
brief loss of consciousness no prodrome, palpitation, any posture
– Unexplained cause
– Heart disease
– Abnormal ECG
Loop ECG monitoring
• Long term monitoring days to months
• Yield24-47%
• Indication– Recurrent syncope – Normal heart
Electrophysiological study
• Indication– Known heart disease– Abnormal ventricular function– Abnormal ECG or Holter monitoring
• Bundle branch block
• Isolated conduction disease
• Ventricular tachyarrhythmias
Echocardiography
• Indication – Heart disease– Arrhythmias– Abnormal ECG
• Yield 5-10%
• 10 times more costly
Tilt table testing
• Yield– Passive 49% (26-90%) – Isoproterenol 64% (39-87%)
• Response– Two third cardioinhibitory– One third vasodepressor
• Protocols variable– Duration 5-60min– Tilt angle 60-90 degree– Isoproterenol dose 1-2micgm/min
Tilt table testing
• Sensitivity– 67-89% in Neurocardiac syncope
• Specificity– 90% for passive testing– 75% for Isoproterenol testing
• Reproducibility– 67-85%
Neurologic testing
• EEG– Poor yield– HO seizure
• CT brain– Low yield– Focal neurologic
signs
• Neurovascular studies– Doppler– Angiogram– Low yield in
unselected cases– VBI
Group A Neuro-circulatory
A. Diagnosed by History
and Examination
– Neurocardiac
– Orthostatic
– Situational
– Drug induced
B. Idiopathic
– Tilt table
– Loop monitor
– EP
– EEG
Group B Cardiac
A. Obstructive
– Echocardiogram
– Cardiac cath
– Lung scan
B. Arrhythmic
– Holter
– Loop Monitor
– EP study
Group C Neurological
A.Seizure
– EEG
– CT/MR
B. CVA
– Doppler
– CT/MR
– Angiography
S y n co p e D ia g n o stic A lg o r ith m
T reatNeu rocard iacO rth os ta tic
S itu a tion a l/D ru g
Diagnosed
T ilt tableL oop
E EG /E PP sy
Unknow n
Norm al Exam ination
EchoS tressC ath
OBS
HolterS tressL oopE P
Arrhythm ic
Cardiac
EEGCT/M R
Seizure
DopplerCT/M RA ng io
CVA
Neurological
HistoryExam ination
ECG
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