‘Patients with suspected syncope should be investigated by
cardiologists’
Antagonist
Maw Pin TanLocum Consultant Physician
Falls and Syncope ServiceRoyal Victoria InfirmaryNewcastle upon Tyne
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