Syncope – ESC 2018

  • Defintion:Transient Loss of Consciousness (TLOC) due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery.
  • Common ED Complaint: 1.7% of all attendances
  • Difficult Diagnosis: less than 50% get a diagnosis in ED
  • Mortality & Serious Outcome: 0.8% mortality & 10.3% serious outcome @ 30 days

Ask 3 Questions!

  1. Is this Syncope?
  2. What is the underlying cause?
  3. What is the best Follow-Up for this patient?

Q1. Is this syncope?

This will take careful history taking from the patient, witnesses, and ambulance crew (lots of useful info is often found on the PRF).

  1. Was there a TLOC?
  2. Was the TLOC: Rapid Onset, Short Duration & Spontaneous Recovery?

If you can’t answer YES to both of these questions then it is not syncope and think about Conditions easily confused with syncope


  • ECG
  • Postural BP  – not just 2 quick BP’s
    • Do BP @ 0, 1, 3, 5 min
    • Monitor HR – look for reflex tachys
    • Be aware of transient drops – if you monitored an art. line instead you would see drops in the BP that last seconds that can cause the patient to fall.
    • Is the patient symptomatic? – if the patient is symptomatic even without a postural drop (found) its likely a transient drop you have missed and we need to consider reviewing their hypertensive meds
    • Don’t admit ALL postural drops – in the elderly population it’s very common if you’re asymptomatic and have nothing else to cause admission you probably don’t need  admission.
  • Blood tests: FBC & U&E
    • Consider others depending on you history and examination.


Q2. What’s the cause?

Reflex syncope
Orthostatic syncope
Cardiac syncope
Recurrent syncope

<40 years

After unpleasant stimulus: sight/sound/smell/pain

Prolonged standing

During meal

In crowded/hot places

Presyncopal symps: pallor/sweating/nausea/vomiting

With head rotation/pressure on carotid sinus (as in tumours,shaving, tight collars)

Absence of heart disease

While/after standing

Prolonged standing

Standing after exertion


Start/changes of Antihypertensives or diuretics 

Presence of autonomic neuropathy/Parkinsonism

During exertion/when supine

Sudden onset palpitation immediately followed by syncope

Family history of unexplained sudden death @ young age

Presence of structural heart disease or coronary artery disease


ECG findings suggesting arrhythmic syncope:


Q3. What Follow-Up is best?

LOW-Risk Features





Typical of Reflex OR Orthostatic Syncope


Long Hx(years) of similar low risk events

No structural heart disease

Normal Normal

HIGH-Risk Features






New Onset: Chest pain/SOB/Abdo pain/Headache

During exertion/supine

Sudden onset palpitations immediately followed by syncope


Severe structural/coronary artery disease

  • Heart failure
  • Low LVEF
  • MI

sBP <90mmHg

Evidence of GI bleed

Undiagnosed systolic murmur



No Prodrome or short(<10s)

FHx of sudden cardiac death @ young age

Syncope while sitting


Minor features: High-Risk ONLY if Hx consistent with arrhythmic syncope.


How to Follow up?

LOW-Risk (ONLY): These patients will generally have reflex or orthostatic syncope, and can generally be discharged for GP follow-up. Although you may want to review their medication or have a frailty review.

HIGH-Risk (ANY): These patients have a high risk of death or serious outcome and would benefit from investigation as an inpatients.

Neither: These patients would likely benefit from early investigations and follow-up, this could be through AAU or syncope clinic

Remember: These patients may require admission for other reasons beyond syncope, e.g upper GI bleed or PE causing syncope(its not the syncope that will kill them).


European Society of Cardiology – 2018 syncope guideline

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