Syncope Clinical Management in the Emergency Department
- Costantino G, Sun BC, Barbic F, et al.
- Syncope Clinical Management in the Emergency Department: A Consensus From the First International Workshop on Syncope Risk Stratification in the Emergency Department. Eur Heart J 2015;Aug 4:[Epub ahead of print].
The following are 10 key points to remember from the consensus document on syncope management in the emergency department (ED):
- Extensive practice variation, high costs, and questionable benefit associated with some current approaches are undesirable features of syncope evaluation in the ED. Multi-specialty workshop of North American and European syncope experts aimed to write a consensus on the best way to manage syncope patients in the ED.
- Syncope is defined as a transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery.
- The patient’s assessment should include history, physical examination, electrocardiography (ECG), supine and standing blood pressure measurement, and subsequent tests (such as blood sampling, carotid sinus massage, echocardiogram, chest X-ray, blood gas analysis), according to clinical characteristics and physician judgment.
- It is unknown if hospitalization can reduce adverse events in patients with unexplained syncope. The decision to admit a patient should take into account cost, possible adverse events related to hospitalization, and the clinical utility of hospitalization.
- Although there is increasing interest in the use of biomarkers for syncope risk stratification, including troponins and brain natriuretic peptides, these biomarkers cannot be recommended for routine care at present.
- High-risk patients are those who have at least one high-risk characteristic:
- Syncope during exertion, in supine position, associated with new onset of chest discomfort, and palpitations before syncope;
- Family history of sudden death;
- Heart failure, aortic stenosis, left ventricular outflow tract disease, dilated cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular ejection fraction <35%, previously documented ventricular arrhythmia, coronary artery disease, congenital heart disease, previous myocardial infarction, pulmonary hypertension, previous implantable cardioverter-defibrillator implantation;
- Hemoglobin <9 g/dl, lowest systolic blood pressure in the ED <90 mm Hg, sinus bradycardia <40 bpm; and
- New (or previously unknown) left bundle branch block, bifascicular block and first-degree atrioventricular (AV) block, Brugada ECG pattern, ECG changes consistent with acute ischemia, nonsinus rhythm (new), bifascicular block, prolonged QTc (>450 ms).
- Age <40 years;
- Syncope occurring while in standing position, standing from supine/sitting position; nausea or vomiting before syncope; feeling of warmth before syncope; syncope triggered by painful or emotionally distressing stimulus or by cough, defecation, micturition; and
- Prolonged history (years) of syncope with the same characteristics of the current episode.
- Comorbidities who would otherwise be at low risk,
- Without any comorbidity whose syncope has some worrisome characteristics,
- Without any low- or high-risk characteristics.
- Pause (>3 seconds),
- Sustained or nonsustained ventricular tachycardia whether symptomatic or asymptomatic,
- High-grade AV block,
- Bradycardia (<30 bpm) whether symptomatic or asymptomatic,
- Bradycardia (<50 bpm) in a symptomatic patient, or
- Tachycardia (>120 bpm) in a symptomatic patient.
< Back to Listings