syncope
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Introduction
Definition:
- transient loss of consciousness & postural tone (i.e. falling when standing, slumping over when sitting, etc.) followed by spontaneous recovery without the need for resuscitation
Etiology
(also see causes of syncope)
- inadequate vasoconstrictor mechanisms
- neurocardiogenic vasopressor dysfunction (NVD) accounts for the majority of syncopal episodes in the general population (neurally-mediated syncope)[5]
- vasovagal reaction
- carotid sinus syncope (most common cause in elderly)
- situational syncope
- micturition syncope
- defection syncope
- postprandial syncope
- cough syncope
- heat syncope
- swallowing ?[16]
- postural hypotension (orthostasis)
- postprandial hypotension
- autonomic insufficiency
- primary autonomic insufficiency
- multiple system atrophy[62]
- Parkinson's disease[62]
- sympathectomy, pharmacologic or surgical
- diabetes mellitus [16, 62]
- uremia[16][62]
- spinal cord lesions[62]
- diseases of the CNS & peripheral nervous system
- syncope associated with brainstem neurological signs & symptoms
- posterior circulation vascular disease (vertebrobasilar system)
- increased bradykinin
- vasodilator agent
- tricyclic antidepressants[16]
- neurocardiogenic vasopressor dysfunction (NVD) accounts for the majority of syncopal episodes in the general population (neurally-mediated syncope)[5]
- hypovolemia
- blood loss
- Addison's disease
- dehydration
- diuretics
- venous pooling
- mechanical reduction of venous return
- Valsalva maneuver
- cough
- micturition
- atrial myxoma, ball valve thrombus
- nitrates
- mechanical reduction of venous return
- reduced cardiac output
- obstruction to left ventricular outflow
- obstruction to pulmonary flow
- pulmonic stenosis
- pulmonary embolus (under-diagnosed)[7][29]
- identified in 17% of patients with syncope[53]
- higher-than-expected prevalence of pulmonary embolisn among patients with syncope but without chest pain or dyspnea, 2.2% overall, but 18% of patients with cancer[57]
- pulmonary hypertension
- myocardial infarction with pump failure
- cardiac tamponade
- dilated cardiomyopathy[5]
- negative inotropes
- atrial myxoma[5]
- tachydysrhythmias
- ventricular tachycardia
- atrial fibrillation with rapid ventricular response[60]
- RR of cardiac syncope for atrial fibrillation = 7.3[56]
- AV nodal re-entry tachycardia
- pre-excitation disorder with atrial fibrillation/flutter
- pharmaceuticals
- bradyarrhythmias*
- AV block 2nd & 3rd degree with Stokes-Adams attacks
- ventricular asystole
- sinus bradycardia
- carotid sinus syndrome (most common cause in elderly)
- glossopharyngeal neuralgia & other painful states
- pharmacutical agents
- vascular anomalies
- dissecting aneurysm
- subclavian steal syndrome
- vertebrobasilar TIA[5]
- pulmonary embolism
- 15% of patients evaluated with CTPA or VQ scan[45]
- 1% in hospitalized patients[46]
- < 1% (all patients), 0.4-2.6% in hospitalized patents[48]
- hypoglycemia[16]: hypoglycemic agent
- pharmaceuticals (see above)
- psychogenic pseudosyncope
- idiopathic (20-40%)[8][12][16]
- predisposition to syncope in the elderly
- multifactorial etiology[16]
- decreased arterial compliance
- decreased reflex peripheral vasoconstriction
- systolic hypertension
- left ventricular hypertrophy (LVH)
- diastolic dysfunction
- hypotensive response to increased heart rate, volume depletion or loss of atrial contraction
- also see Differential diagnosis: (below)
* bradyarrhythmia due to carotid sinus syncope most common cause in the elderly[5][16][20]
Epidemiology
- syncope occurs in 30-50% of people at some point in their lives
- 3% of emergency department visits & 1% of hospitalizations are due to syncope
- incidence of syncope increase with age[16]
- age > 50, male sex & known structural heart disease favors cardiac versus neurally-mediated syncope
Pathology
- cerebral hypoperfusion
- age-related changes predispose to syncope
- reduced baroreflex increase in heart rate & sympathetic peripheral vascular constriction
- reduced left ventricular compliance may reduce left ventricular filling with increases in heart rate
- changes in endocrine & renal function may predispose to dehydration[16]
History
- obtain history from
- obtain details on:
- circumstances, place, time, posture, duration
- pattern of syncope, if multiple events
- relationship to: fasting, eating, daily activities or routines, associated illnesses, bodily functions, exertion, sleep deprivation
- premonitory symptoms
- recovery symptoms
- anemia or GI bleeding
- family history may suggest syncope due to arrhythmia
- long QT syndrome
- Brugada syndrome
- hypertrophic obstructive cardiomyopathy
- sudden death
- detailed medication history
- over-medication (generic & brand names)
- vasoactive agents
- arrhythmogenic agents
- recent adjustment of medication doses
- cholinesterase inhibitors (donepezil)
- over-medication (generic & brand names)
- syncope during exercise or exertion or family history of sudden death suggests cardiac cause of syncope[23]
- syncope during exertion suggests hypertrophic cardiomyopathy[5]
- cyanosis witnessed during syncopal episode suggests cardiac syncope[56]
- past medical history
- previous history of syncope or prodrome suggesting vasovagal reaction
- prior history of heart failure, or myocardial infarction
- depression
Physical examination
- vitals
- orthostatic blood pressure & pulse, including supine, sitting & upright for 3 minutes[44]
- cardiac examination (heart sounds, murmurs)
- carotid pulse & auscultation
- focal neurologic deficits[62]
- signs of volume depletion[62]
- gait & balance evaluation
- leg crossing, squatting or hand grip maneuvers for vasovsgal syncope with prolonged prodrome[5]
Clinical manifestations
- nausea &/or diaphoresis
- may precede neurocardiogenic syncope
- may accompany ischemic heart disease in older adults
- onset of syncope due to cardiac dysrhythmia
- generally abrupt (< 5 seconds of warning or no warning)
- palpitations may or may not be noted
- syncope during exertion suggests hypertrophic cardiomyopathy
- syncope during sleep suggests long QT syndrome or Brugada syndrome[5]
- generally abrupt (< 5 seconds of warning or no warning)
- transient loss of consciousness
- loss of postural tone
- orthostatics by far the most useful diagnostic test[5]
- identifies etiology of syncope in 15-21% of cases
- affected diagnosis & management in ~25% of cases[12]
- full recovery generally occurs after a short time
- feeling of fatigue many accompany neurocardiogenic syncope
- little to no post-event confusion
- seizures may occur secondary to syncope
- multifocal myoclonus occurs in most patients with syncope
- vertebrobasilar TIA or stroke
- vertigo more likely than lightheadedness
- blood pressure likely increased
- brain-stem symptoms likely with vertebrobasilar stroke
- urinary incontinence may allegedly occur due to relaxation of urinary sphincter[16]
Laboratory
- complete blood count (CBC) for anemia*
- fecal occult blood[62]
- serum chemistries
- renal function tests
- electrolytes (electrolyte disorder = high short-term risk)[5]
- drug levels of therapeutically monitored drugs
- markers of myocardial infarction of little value[5]
- serum BNP does not improve Canadian Syncope Risk Score[59]
- urine toxicology
* severe anemia = high short-term risk[5]
Diagnostic procedures
- as indicated by history & physical examination[16]
- electrocardiogram
- 12-lead EKG, all patients[16][44][50]
- signal averaged ECG (SAECG) may help predict the occurrence of ventricular tachycardia
- most patients (75%) with cardiac cause of syncope have abnormal electrocardiogram[23]
- non-sustained ventricular tachycardia
- bifasicular block
- sinus bradycardia (< 50/min) or sinoatrial block
- Mobitz type 2 second degree AV block or third degree AV block
- prolonged QT interval[5]
- Q wave[62]
- ST segment elevation, ST segment depression
- T wave changes
- supraventricular tachycardia
- atrial fibrillation
- multiform premature ventricular complexes
- echocardiography
- suspected structural heart disease
- exercise tolerance testing (ETT)
- suspected ischemic heart disease
- syncope during or immediately after exercise
- head-up tilt table test:
- useful in patients with LVEF > 40% in whom neurocardiogenic vasopressor dysfunction (NVD) is suspected, in which delayed orthostatic hypotension develops over 15-45 minutes[16]
- recurrent episodes
- suspected cardiac cause[5]
- ambulatory blood pressure monitoring
- Holter or event recorder (loop recorder)[5][22]
- generally of low yield
- 11% in octagenarians[15]
- 20% in patients >= 90 years of age
- higher in men & higher with structural heart disease
- not indicated in initial evaluation of syncope
- implantable event recorder is useful for identifying an infrequent arrhythmia when previous 30-day monitoring was not successful[5][21]
- generally of low yield
- carotid sinus massage in elderly
- cardiac monitor
- atropine available
- electrophysiologic testing rarely indicated[5]
- patients suspected of having a tachydysrhythmia
- evidence of structural heart disease
- previous myocardial infarction
- bifascicular block on ECG
- impaired ventricular function
- a normal study indicates low risk for life-threatening cause of syncope
- electroencephalogram generally of low yield
- not indicated in initial evaluation of syncope
Radiology
- echocardiogram for suspected structural heart disease[44]
- not necessary with normal ECG & negative serum troponin I[18][58]
- echocardiogram can be ordered independently from ECG if valvular heart disease suspected[16]
- carotid ultrasound of little value[5][10]
- vertebrobasilar ultrasound of little value[10]
- head CT or brain MRI of little value & not recommended in the absence of neurologic signs[5]
Complications
- syncope while driving
- neurally mediated syncope was the most common type
- cumulative probability of recurrent syncope driving is 7% during 8 years[13]
- increased risk of motor vehicle accidents requiring hospital treatment (21 vs 12 per 1000 person-years)[33]
- supine hypertension may result from treatment[16]
- 25% of patients hospitalized with unexplained 1st episode of syncope diagnosed with pulmonary embolism[43]
- 13% of patients with other cause of syncope also with PE
Differential diagnosis
- circulatory (reduced cerebral blood flow)
- vasovagal syncope
- suggested by posture (standing), provoking factors (pain, procedure), prodrome (diaphoresis, nausea)
- carotid sinus hypersensitivity
- pressure on the carotid sinus, tight collar, sudden head turning
- situation syncope
- association with urination (micturition syncope), defecation, swallowing, cough
- orthostatic hypotension
- post-prandial syncope
- cardiopulmonary disease
- obstruction to LV outflow
- cardiac arrhythmia:
- sudden onset, no prodrome
- sinus, atrial & AV node dysfunction
- ischemic heart disease
- beta-blockers, calcium channel blockers & other anti-arrhythmic drugs[5]
- vasovagal syncope
- hypoxia
- hypoventilation
- anemia
- hypoglycemia
- cerebral
- TIA
- brainstem neurologic signs, vertebrobasilar disease, subclavian steal if preceded by upper extremity exercise
- emotional disturbance
- seizure
- diaphoresis or nausea prior to loss of consciousness suggests syncope rather than seizure
- post-ictal state suggests seizure rather than syncope
- information from observers can contribute in differentiating epilepsy from syncope or psychogenic seizures[54]
- diffuse spasm of cerebral arterioles (hypertensive encephalopathy)
- TIA
- emotional disturbances
- anxiety
- hysterical seizures
- cataplexy
- no loss of consciousness (recollection of event)
- sudden loss of muscle strength & muscle tone
- provoked by laughter or anticipatory emotion
- sleep attack
Management
- hospitalization if indicated
- San Francisco Syncope Rule (best studied)
- Boston Syncope Criteria
- EGSYS score
- Canadian syncope risk score[42][61]
- ROSE index[5]
- syncope associated with exercise or exertion[16]
- concern for structural heart disease (i.e. valvular heart disease) based on clinical examination[5]
- syncope evaluation units may become standard of care (see SEEDS)
- most patients can be safely managed as outpatients[5][61]
- hospitalization of elderly does not change in the rate of serious adverse events or mortality[55]
- arrhythmias
- hospitalization with cardiac monitoring is indicated when cardiac syncope is likely[5]
- treat underlying heart disease
- correct metabolic abnormalities
- consider pacemaker or implantable automatic defibrillator
- if < 40 years, recurrent exertional dyspnea, cardiac arrest, or near drowning, genetic testing is indicated
- see specific arrhythmia
- neurocardiogenic vasopressor dysfunction (NVD)
- general measures
- adequate hydration
- consider liberalizing salt intake if hypotensive
- use caution with changes in postural position
- lie down or place head below heart to abort symptoms
- obtain orthostatic blood pressures (supine, sitting, standing)
- reduce or stop offending medications
- antihypertensives (especially diuretics)
- compression stockings may reduce risk of vasovagal reaction by preventing pooling of blood in lower extremities[16]
- smaller low carbohydrate meals with postprandial hypotension[62]
- adequate hydration
- pharmacologic therapy
- beta-blockers (cardioselective {beta-1} best)
- block orthostatic increase in heart rate in patients with diastolic dysfunction
- midodrine or fludrocortisone for orthostatic hypotension
- pyridostigmine may helpful for supine hypertension & orthostatic hypotension
- disopyramide
- theophylline
- anticholinergic agents
- serotonin reuptake inhibitors
- beta-blockers (cardioselective {beta-1} best)
- general measures
- anemia
- consider hospitalization for syncope associated with hematocrit < 30%[5]
- in elderly
- treatment of multiple underlying causes may be indicated[16]
- treat presyncope as syncope[52]
- prognosis[8][9]
- 22% have multiple episodes (78% do NOT)
- cardiac syncope have 2-fold increased risk of death & 3-fold increased risk of myocardial infarction
- idiopathic cases have 32% increased risk of death & 31% increased risk of myocardial infarction
- No increased risk of death with syncope due to vasovagal reactions, orthostasis or drugs
- San Francisco syncope rule predicts serious outcomes[9]
- 1.4% of patients San Francisco Syncope Rule-negative will have a 7-day serious outcome[30]
- risk of motor vehicle accident following emergency department visit for syncope is not increased in the following year[64]
More general terms
More specific terms
- convulsive syncope
- heat syncope
- neurocardiogenic vasopressor dysfunction; neurally-mediated syncope; reflex syncope (NVD)
- orthostatic syncope
- situational syncope
Additional terms
- Boston Syncope Criteria
- Canadian Syncope Risk Score
- causes of syncope
- Evaluation of Guidelines in SYncope Study score (EGSYS score)
- FAINT score
- San Francisco syncope rule
- Syncope Evaluation in the Emergency Department Study (SEEDS)
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 27-28
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 204-205
- ↑ Chan & Winkle, Diagnostic History & Physical Examination, Current Clinical Strategies Publishing. Laguna Hills, 1996
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 82
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 5.24 5.25 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 38, 100-104
- ↑ 7.0 7.1 Wilk et al, Geriatrics 50:46, 1995
- ↑ 8.0 8.1 8.2 Journal Watch 22(20):153, 2002 Soteriades ES et al, N Engl J Med 347:878, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12239256
- ↑ 9.0 9.1 9.2 Journal Watch 24(6):50, 2004 Quinn JV et al, Ann Emerg Med 43:224, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14747812
- ↑ 10.0 10.1 10.2 Journal Watch 25(10):79, 2005 Schnipper JL, Ackerman RH, Krier JB, Honour M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope. Mayo Clin Proc. 2005 Apr;80(4):480-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15819284
- ↑ 11.0 11.1 Thijs RD et al. Transient loss of consciousness through the eyes of a witness. Neurology 2008 Nov 18; 71:1713. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19015487
- ↑ 12.0 12.1 12.2 Mendu ML et al Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med 2009 Jul 27; 169:1299 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19636031
Heidenreich PA. Assessing the value of a diagnostic test. Arch Intern Med 2009 Jul 27; 169:1262 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19636026
Quinn JV Yield of diagnostic tests in evaluating syncopal episodes in older patients [invited commentary]. Arch Intern Med 2009 Jul 27; 169:1305. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19636032 - ↑ 13.0 13.1 Sorajja D et al Syncope while driving: Clinical characteristics, causes, and prognosis. Circulation 2009 Sep 15; 120:928 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19720940
- ↑ Epstein AE et al Personal and Public Safety Issues Related to Arrhythmias That May Affect Consciousness: Implications for Regulation and Physician Recommendations Circulation. 1996 94:1147-1166 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/8790068 <Internet> http://circ.ahajournals.org/cgi/content/full/94/5/1147
- ↑ 15.0 15.1 Kuhne M et al. Holter monitoring in syncope: Diagnostic yield in octogenarians. J Am Geriatr Soc 2011 Jul; 59:1293 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21718271
- ↑ 16.00 16.01 16.02 16.03 16.04 16.05 16.06 16.07 16.08 16.09 16.10 16.11 16.12 16.13 16.14 16.15 16.16 16.17 16.18 16.19 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ Grossman SA et al. Reducing admissions utilizing the Boston Syncope Criteria. J Emerg Med 2012 Mar; 42:345. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21421292
- ↑ 18.0 18.1 Anderson KL et al. Cardiac evaluation for structural abnormalities may not be required in patients presenting with syncope and a normal ECG result in an observation unit setting. Ann Emerg Med 2012 Oct; 60:478. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22632775
- ↑ Cooper PN et al. Synopsis of the National Institute for Health & Clinical Excellence guideline for management of transient loss of consciousness. Ann Intern Med 2011 Oct 18; 155:543 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21930835
Brigo F et al. Value of tongue biting in the differential diagnosis between epileptic seizures and syncope. Seizure 2012 Oct; 21:568 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22770819
D'Ascenzo F et al. Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the Emergency Department with syncope: An international meta-analysis. Int J Cardiol 2011 Dec 22 http://www.internationaljournalofcardiology.com/article/S0167-5273(11)02140-1/fulltext
Saccilotto RT et al. San Francisco Syncope Rule to predict short-term serious outcomes: A systematic review. CMAJ 2011 Oct 18; 183:E1116 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21948723 - ↑ 20.0 20.1 Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS), Moya A, Sutton R, Ammirati F et al Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009 Nov;30(21):2631-71 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19713422
- ↑ 21.0 21.1 Parry SW, Matthews IG. Implantable loop recorders in the investigation of unexplained syncope: a state of the art review. Heart. 2010 Oct;96(20):1611-6 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20937748
- ↑ 22.0 22.1 Subbiah R, Gula LJ, Klein GJ, Skanes AC, Yee R, Krahn AD. Syncope: review of monitoring modalities. Curr Cardiol Rev. 2008 Feb;4(1):41-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19924276
- ↑ 23.0 23.1 23.2 Tretter JT and Kavey R-EW Distinguishing cardiac syncope from vasovagal syncope in a referral population. J Pediatr 2013 Aug 27 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23992679 <Internet> http://www.jpeds.com/article/S0022-3476(13)00881-0/abstract
- ↑ Ouyang H, Quinn J. Diagnosis and evaluation of syncope in the emergency department. Emerg Med Clin North Am. 2010 Aug;28(3):471-85 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20709239
- ↑ Parry SW, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ. 2010 Feb 19;340:c880 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20172928
- ↑ Reed MJ1, Newby DE, Coull AJ, Prescott RJ, Jacques KG, Gray AJ The ROSE (risk stratification of syncope in the emergency department) study. J Am Coll Cardiol. 2010 Feb 23;55(8):713-21. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20170806 J Am Coll Cardiol. 2010 Feb 23;55(8):722-4
Benditt DG, Can I. Initial evaluation of "syncope and collapse" the need for a risk stratification consensus. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20170807 - ↑ Serrano LA, Hess EP, Bellolio MF et al Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2010 Oct;56(4):362-373.e1 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20868906
- ↑ Sun BC, Derose SF, Liang LJ et al Predictors of 30-day serious events in older patients with syncope. Ann Emerg Med. 2009 Dec;54(6):769-778.e1-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19766355
- ↑ 29.0 29.1 Kabrhel C Case 29-2014 - A 60-Year-Old Woman with Syncope. N Engl J Med 2014; 371:1143-1150September 18, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25229919 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcpc1403307
- ↑ 30.0 30.1 Goble MM, Benitez C, Baumgardner M, Fenske K. ED management of pediatric syncope: searching for a rationale. Am J Emerg Med. 2008 Jan;26(1):66-70. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18082784
- ↑ Massin MM, Bourguignont A, Coremans C et al Syncope in pediatric patients presenting to an emergency department. J Pediatr. 2004 Aug;145(2):223-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15289772
- ↑ The NNT: Risk Assessment: Syncope in the Emergency Department. http://www.thennt.com/risk/syncope-in-the-emergency-department/
- ↑ 33.0 33.1 Nume AK, Gislason G, Christiansen CB et al Syncope and Motor Vehicle Crash RiskA Danish Nationwide Study. JAMA Intern Med. Published online February 29, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26927689 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=2497782
Redelmeier DA, Raza S Syncope and the Risk of a Subsequent Motor Vehicle Crash. JAMA Intern Med. Published online February 29, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26926948 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=2497779 - ↑ Brignole M, Hamdan MH. New concepts in the assessment of syncope. J Am Coll Cardiol. 2012 May 1;59(18):1583-91. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22538328 Free Article
- ↑ Ebell MH. Risk stratification of patients presenting with syncope. Am Fam Physician. 2012 Jun 1;85(11):1047-52. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22962874 Free Article
- ↑ Rosanio S, Schwarz ER, Ware DL, Vitarelli A. Syncope in adults: systematic review and proposal of a diagnostic and therapeutic algorithm. Int J Cardiol. 2013 Jan 20;162(3):149-57. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22188993
- ↑ Puppala VK, Dickinson O, Benditt DG. Syncope: classification and risk stratification. J Cardiol. 2014 Mar;63(3):171-7. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24405895 Free Article
- ↑ Costantino G, Furlan R. Syncope risk stratification in the emergency department. Cardiol Clin. 2013 Feb;31(1):27-38. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23217685
- ↑ Duplyakov D, Kurakina E, Pavlova T, Khokhlunov S, Surkova E. Value of syncope in patients with high-to-intermediate risk pulmonary artery embolism. Eur Heart J Acute Cardiovasc Care. 2015 Aug;4(4):353-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24619817
- ↑ Benditt DG, Adkisson WO. Approach to the patient with syncope: venues, presentations, diagnoses. Cardiol Clin. 2013 Feb;31(1):9-25. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23217684
- ↑ Stephenson JB. Syncopes and other paroxysmal events. Handb Clin Neurol. 2013;112:861-6. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23622295
- ↑ 42.0 42.1 Thiruganasambandamoorthy V, Kwong K, Wells GA et al. Development of the Canadian syncope risk score to predict serious adverse events after emergency department assessment of syncope. CMAJ 2016 Sep 6; 188:E289. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27378464 Free PMC Article <Internet> http://www.cmaj.ca/content/188/12/E289
- ↑ 43.0 43.1 Prandoni P, Lensing AW, Prins MH et al Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med 2016; 375:1524-1531. October 20, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27797317 Free Article <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1602172
- ↑ 44.0 44.1 44.2 44.3 Orciari Herman A, Sofair A, Chavey WE First U.S. Guidelines Issued on Syncope Management Physician's First Watch, March 10, 2017 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
Shen WK, Sheldon RS, Benditt DG et al 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2017 Mar 9. pii: S0735-1097(17)30792-1. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28286222
Shen WK, Sheldon RS, Benditt DG et al 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2017 Mar 9. pii: S0735-1097(17)30793-3. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28286221 j.jacc.2017.03.003.full.pdf from <Internet> http://www.onlinejacc.org - ↑ 45.0 45.1 Verma AA, Masoom H, Rawal S et al Pulmonary Embolism and Deep Venous Thrombosis in Patients Hospitalized With Syncope. A Multicenter Cross-sectional Study in Toronto, Ontario, Canada JAMA Intern Med. Published online May 8, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28492876 <Internet> http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2626191
- ↑ 46.0 46.1 Oqab Z, Ganshorn H, Sheldon R. Prevalence of pulmonary embolism in patients presenting with syncope. A systematic review and meta-analysis. Am J Emerg Med 2017 Sep 13; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28947223 <Internet> http://www.ajemjournal.com/article/S0735-6757(17)30740-4/fulltext
- ↑ Al-Khatib SM et al. AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017 Oct 30 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29084731 <Internet> http://circ.ahajournals.org/content/early/2017/10/30/CIR.0000000000000549
- ↑ 48.0 48.1 Costantino G, Ruwald MH, Quinn J et al Prevalence of Pulmonary Embolism in Patients With Syncope. JAMA Intern Med. Published online January 29, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29379959 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2670036
- ↑ Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 Mar 19. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29562304 https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehy037/4939241
Brignole M, Moya A, de Lange FJ et al Practical Instructions for the 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 Mar 19. doi:http://dx.doi.org/ 10.1093/eurheartj/ehy071. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29562291 - ↑ 50.0 50.1 Waytz J, Cifu AS, Stern SDC Evaluation and Management of Patients With Syncope. JAMA. 2018;319(21):2227-2228. June 5, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29872846 https://jamanetwork.com/journals/jama/fullarticle/2683204
- ↑ Ruwald MH, Zareba W. ECG monitoring in syncope. Prog Cardiovasc Dis. 2013 Sep-Oct;56(2):203-10. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24215752
- ↑ 52.0 52.1 Bastani A, Su E, Adler DH et al. Comparison of 30-day serious adverse clinical events for elderly patients presenting to the emergency department with near-syncope versus syncope. Ann Emerg Med 2018 Dec 7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30529112 https://www.annemergmed.com/article/S0196-0644(18)31420-3/fulltext
- ↑ 53.0 53.1 Thiruganasambandamoorthy V, Sivilotti MLA, Rowe BH et al. Prevalence of pulmonary embolism among emergency department patients with syncope: A multicenter prospective cohort study. Ann Emerg Med 2019 Jan 25; PMID: https://www.ncbi.nlm.nih.gov/pubmed/30691921 https://www.annemergmed.com/article/S0196-0644(18)31535-X/fulltext
- ↑ 54.0 54.1 Chen M et al. Value of witness observations in the differential diagnosis of transient loss of consciousness. Neurology 2019 Feb 26; 92:e895 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30804064 https://n.neurology.org/content/92/9/e895
- ↑ 55.0 55.1 Probst MA, Su E, Weiss RE et al. Clinical benefit of hospitalization for older adults with unexplained syncope: A propensity-matched analysis. Ann Emerg Med 2019 May 9 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31080027 https://www.annemergmed.com/article/S0196-0644(19)30250-1/fulltext
- ↑ 56.0 56.1 56.2 Albassam OT, Redelmeier RJ, Shadowitz S et al. Did this patient have cardiac syncope? The rational clinical examination systematic review. JAMA 2019 Jun 25; 321:2448. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31237649
- ↑ 57.0 57.1 Raynal PA, Cachanado M, Truchot J et al. Prevalence of pulmonary embolism in emergency department patients with isolated syncope: A prospective cohort study. Eur J Emerg Med 2019 Dec; 26:458 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31609876 https://insights.ovid.com/crossref?an=00063110-201912000-00017
- ↑ 58.0 58.1 Ghani AR, Ullah W, Abdullah HMA et al. The role of echocardiography in diagnostic evaluation of patients with syncope-a retrospective analysis. Am J Cardiovasc Dis 2019 Oct 15; 9:78. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31763059 Free PMC Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6872465/
- ↑ 59.0 59.1 Thiruganasambandamoorthy V, McRae AD, Rowe BH et al. Does N-terminal pro-B-type natriuretic peptide improve the risk stratification of emergency department patients with syncope? Ann Intern Med 2020 Apr 28; PMID: https://www.ncbi.nlm.nih.gov/pubmed/32340039 https://annals.org/aim/article-abstract/2765186/does-n-terminal-pro-b-type-natriuretic-peptide-improve-risk
- ↑ 60.0 60.1 Malik V, Gallagher C, Linz D et al Atrial Fibrillation Is Associated With Syncope and Falls in Older Adults: A Systematic Review and Meta-analysis. Mayo Clin Proc. 2020 Apr;95(4):676-687. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32247342
- ↑ 61.0 61.1 61.2 Krishnan RJ et al. Benefit of hospital admission for detecting serious adverse events among emergency department patients with syncope: A propensity-score-matched analysis of a multicentre prospective cohort. CMAJ 2020 Oct 13; 192:E1198. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33051314 PMCID: PMC7588246 Free PMC article https://www.cmaj.ca/content/192/41/E1198
- ↑ 62.0 62.1 62.2 62.3 62.4 62.5 62.6 62.7 62.8 62.9 Talebraza S et al Geriatrics Evaluation & Management Tools American Geriatrics Society. 2021 https://geriatricscareonline.org/ProductAbstract/geriatrics-evaluation-management-tools/B007/
- ↑ Shen WK, Sheldon RS, Benditt DG et al 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e25-e59 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28280232
Shen WK, Sheldon RS, Benditt DG et al 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e60-e122. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28280231 Review. - ↑ 64.0 64.1 Staples JA, Erdelyi A, Merchant K et al Syncope and the Risk of Subsequent Motor Vehicle Crash.A Population-Based Retrospective Cohort Study. JAMA Intern Med. Published online August 1, 2022. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35913711 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2794651
- ↑ National Institute of Neurological Disorders and Stroke (NINDS) NINDS Syncope Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Syncope-Information-Page