Differential Diagnosis of Syncope

Major categories of syncope

o Vasovagal/Reflex/Fainting
Visceral organ stimulation
Carotid body stimulation
Psychogenic situational, reproducible, no prodrome
o Orthostatic
Volume depletion diarrhea, dehydration, diuresis, hemorrhage
ANS dysfunction
o Cardiac
Mechanical/Sudden CO disruption AS or HOCM, MI/PE/TP
Exertional, Dx=echo
Arrhythmias
Sudden, no prodrome, Dx=EKG, Holter monitor, Event recorder
o Neurogenic/Vascular poor post. brain circulation
Sudden, no prodrome, FNDs!!! (think arrhythmia if no FND and sudden)
If FND or SAH history get CT
LOC rarely if ever isolated symptom if this is cause
Dx= Carotid U/S, CTA (best)
First determine it was actually syncope
o Transient, self-limited LOC, caused by reduced blood to brain
<20 sec, almost immediate restoration of behavior and orientation
often preceded by sweating or nausea, standing
more common in age >45
o Loss of postural tone often falling
o Differentiate from vertigo, presyncope, and dizziness no LOC
o Do not confuse syncope with other LOC causes
Seizure major head injury, tongue biting, aura, postictal confusion,
bowel/bladder loss, unusual posturing
Hypoxia, hypoglycemia, intoxication, hyperventilation
o HISTORY is most important
Once determined syncope:
Rule out life threatening causes
o Rule of 15s 15% present with syncope: SAH, ACS, aortic dissection, leaking
AAA, and ruptured ectopic pregnancy
o Also consider CO tox.
o Cardiovascular causes are most common life-threatening conditions associated
with syncope
Rule out blood loss GI/vaginal bleed, AAA leak, trauma, on anticoag?
Measure vitals (including orthostatics)
o Orthostatics contraindicated in supine hypotension (suggested by SBP <90),
physical injuries/limitations, shock, severe AMS
 o Orthostatics + if: SBP dec by 20 or DBP by 10; dizziness/syncope upon standing
may also be considered positive (not official guidelines)
o Causes of orthostatic hypotension
Volume depletion (give IVF and resolves)
ANS dysfunction DM, Parkinsons, Age
Medication nitrates, TCAs, levodopa, anti-hypertensives
Once ruled out orthostatics, check cardiac sources
o Echo, EKG/Holter/Event Monitor, Echo
Look for associated symptoms
o Pelvic or abdominal pain GI/pelvic bleed, leaking aortic aneurysm (back pain)
o Chest pain or dyspnea MI, PE, tension pneumo, dissecting aortic aneurysm
o Neurological symptoms (headache, diplopia, vertigo) - basilar artery
insufficiency, migraine, and subclavian steal syndrome
Other clues
o Position of patient at time of LOC
Lying down cardiac arrhythmia
Standing orthostatic or vasovagal
o Related to physical exertion cardiac outflow obstruction (AS, HOCM, myxoma),
sometimes arrhythmia
Risk stratification
o CHESS Pneumonic predicts serious outcomes at 1 week (Sn = 97%, Sp = 62%)
CHF history
Hct <30%
Abnormal EKG
SOB
SBP <90
Also: age > 75, FH of sudden cardiac death, abnormal EKG on
presentation, history of heat disease