‘Patients with suspected syncope should be investigated by cardiologists’

‘Patients with suspected syncope should be investigated by

cardiologists’

Antagonist

Maw Pin TanLocum Consultant Physician

Falls and Syncope ServiceRoyal Victoria InfirmaryNewcastle upon Tyne

• http://www.nice.org.uk

Guideline Development Group

NICE guidelines for TLoC

• 1.2.3.1 Refer all people with TLoC (apart from the

exceptions below) for a specialist cardiological

assessment

Exceptions are:

• people with a firm diagnosis, after the initial assessment, of:– uncomplicated faint – situational syncope – orthostatic hypotension

• people whose presentation is strongly suggestive of epileptic seizures.

cardiovascular

by the most appropriate local service

Points

• Syncope is a problem of older people• Who is best skilled to conduct the

assessments?• Overlap between epilepsy and syncope• Overlap between falls and syncope• Most common cause– neurally-mediated

syncope

Incidence of Syncope

Soteriades et al. NEJM 2002

1.3.1.1 Carry out a specialist cardiovascular assessment as follows.

• Reassess the person’s: − detailed history of TLoC including any previous events− medical history and any family history of cardiac disease or an

inherited cardiac condition− drug therapy at the time of TLoC and any subsequent changes.

• Conduct a clinical examination, including full cardiovascular examination and, if clinically appropriate, measurement of lying and standing blood pressure.

• Repeat 12-lead ECG and obtain and examine previous ECG recordings.

WHO?

Overlap between Epilepsy and Syncope

• Syncope presenting as epilepsy1

– 74 recurrent ‘seizure-like’ activity– 26% HUT+, 10% CSM+– 42% alternative diagnosis

• Epilepsy presenting as syncope2

– Ictal bradycardia1. Zaidi et al JACC 20002. Tinuper et al Brain 2001;124:2361-71

Overlap between Falls & Syncope

• CSH – unexplained falls1

– Drop attacks2

• Amnesia for LOC3

McIntosh et al. Age Ageing 1993

1. Richardson et al PACE 1997

2. Parry et al JAGS 20053. Parry et al Heart 2005

Causes of Syncope

Parry & Tan BMJ 2010