Assessment of syncope

history of coronary artery disease (CAD); risk factors for CAD (increasing age, male, hypertension, diabetes, obesity, hyperlipidaemia); chest pain, palpitations, dyspnoea, weakness, lightheadedness

pale, diaphoretic; may have low BP; may be brady- or tachycardic; audible S3 or S4; jugular venous distension if right ventricular failure from inferior wall myocardial infarction (MI); signs of congestive heart failure (CHF) such as peripheral oedema and bibasilar rales

recent or remote myocardial infarction (MI); history of coronary artery disease, previous cardiac arrest, mitral or aortic valve stenosis, or structural heart disease; family history of sudden death; may occur in the supine position or with exertion; absent or brief prodrome (<5 seconds) of palpitation and lightheadedness preceding syncope; valve replacement within the last 6 months

may be asymptomatic at presentation with no physical finding; or hypoxemia, pulmonary rales, jugular venous distension, and hypotension

older age; history of coronary artery disease or structural heart disease; use of medicines resulting in atrioventricular (AV) block (such as beta-blockers, calcium-channel blockers, amiodarone); dizziness; fatigue; pre-syncope

bradycardia; irregular pulse; cannon a-waves in the jugular venous pulsation (if third-degree block)

history of coronary artery disease or structural heart disease; may occur in the supine position; history of pre-syncope; chest pain, dyspnoea, blurred vision, weakness, and palpitations before syncope[26]Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001 Jun 1;37(7):1921-8. https://www.sciencedirect.com/science/article/pii/S0735109701012414?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/11401133?tool=bestpractice.com

irregularly irregular pulse with or without rapid ventricular rate; sign of congestive heart failure (CHF) such as pulmonary rales, jugular venous distension, hypotension

palpitations, fatigue, dyspnoea, pre-syncope, orthopnoea, paroxysmal nocturnal dyspnoea

pulmonary congestion; S3 gallop; lower extremity oedema, jugular venous distension

dizziness, lethargy, decreased urine output; history of cause, such as vomiting, diarrhoea, or excessive diuretic use

tachycardia, hypotension, dry mucosa, poor skin turgor

lightheadedness, weakness, palpitations, dyspnoea, angina

bradycardia; a sinus pause >3 seconds; heart rate does not change with Valsalva manoeuvre

exertional dyspnoea, angina, dizziness, syncope; late stages develop congestive heart failure (dyspnoea, paroxysmal nocturnal dyspnoea, peripheral oedema)

harsh ejection systolic murmur that radiates to carotids, murmur loudest at the left sternal edge and on squatting, and softer with Valsalva and isometric exercises; slow rising pulse; low carotid volume; S4 with systolic thrill; signs of congestive heart failure (pulmonary rales, lower extremity oedema, jugular venous distension, hepatomegaly)

history of peptic ulcer disease; history of aspirin or non-steroidal anti-inflammatory drug use; history of alcohol excess; epigastric abdominal pain; haematemesis; melaena; dizziness

tachycardia, hypotension, abdominal tenderness and guarding; decreased bowel sounds; digital rectal examination showing melaena or positive faecal occult blood

history of diverticular disease; weight loss; constipation; abdominal pain; rectal bleeding

tachycardia, hypotension, abdominal tenderness and guarding; decreased bowel sounds; digital rectal examination showing mass or positive for faecal occult blood

recurrent episodes; duration of symptoms >4 years; history of pre-syncope; prodromal symptoms such as nausea and vomiting; precipitated by sudden exposure to unpleasant sight, smell, or noxious stimuli, coughing, swallowing, defecation, micturition, Valsalva manoeuvre (e.g., trumpet playing), postprandial, head rotation or pressure on carotid sinus (e.g., tight collars, shaving), prolonged standing; history of cardiac disease is usually absent

hypotension; bradycardia; may be a carotid bruit; if carotid hypersensitivity: carotid massage causes reduction in systolic BP ≥50 mmHg and/or sinus pause ≥3 seconds; carotid sinus massage should not be performed in patients who have experienced transient ischaemic attack or stroke within the past 3 months or in patients with carotid bruits (unless carotid Doppler studies convincingly exclude significant carotid artery narrowing).[11]Brignole M, Moya A, de Lange FJ, et al. 2018 ESC guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 Jun 1;39(21):1883-948. https://academic.oup.com/eurheartj/article/39/21/1883/4939241 http://www.ncbi.nlm.nih.gov/pubmed/29562304?tool=bestpractice.com

precipitated by standing up, prolonged standing, or strenuous activity; may be other features of autonomic dysfunction, such as erectile dysfunction or disturbed micturition; history of medications causing hypotension or recent change of dosage; history of Parkinson's disease, diabetes, or Shy-Drager syndrome

BP and heart rate are obtained while patient is supine then while standing; orthostatic hypotension if 20 mmHg drop in systolic BP or 10 mmHg drop in diastolic BP within 3 minutes of standing; postural tachycardia syndrome if absence of a significant change in BP within 5 minutes of standing or upright tilt with an increase in heart rate of ≥30 bpm associated with manifestations of orthostatic intolerance[34]Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011 Apr;21(2):69-72. http://www.ncbi.nlm.nih.gov/pubmed/21431947?tool=bestpractice.com

associated with basilar artery migraine, premonitory aura terminates in loss of consciousness that is slow in onset; occipital headache associated with diplopia, vertigo, tinnitus, visual changes, and syncope; strong association with menstrual cycle

no significant physical finding on examination

younger age (<45 years); duration of unconsciousness >5 minutes; sudden onset or brief aura (deja vu, olfactory, gustatory, visual); disorientation and drowsiness following an event; urinary or faecal incontinence; tonic-clonic movements

tongue biting, particularly if it is lateral, has a high specificity for convulsive seizures; disorientation[9]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):e60-122. https://www.ahajournals.org/doi/abs/10.1161/CIR.0000000000000499 http://www.ncbi.nlm.nih.gov/pubmed/28280231?tool=bestpractice.com [27]Brigo F, Nardone R, Bongiovanni LG. Value of tongue biting in the differential diagnosis between epileptic seizures and syncope. Seizure. 2012 Oct;21(8):568-72. https://www.seizure-journal.com/article/S1059-1311(12)00151-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/22770819?tool=bestpractice.com

pre-syncope, palpitations, lightheadedness; history of recurrent tachycardia/supraventricular tachycardia; family history of sudden cardiac death

diaphoretic, tachycardia

underlying cause such as myocardial infarction (MI), aortic dissection, or trauma; may present insidiously as a result of pericarditis or, rarely, hypothyroidism; dizziness; dyspnoea; fatigue

hypotension, distended neck veins, muffled heart sounds; pulsus paradoxus (a drop of ≥10 mmHg in arterial blood pressure on inspiration)

chest and back pain, tearing in nature; history of connective tissue disease, such as Ehlers-Danlos syndrome or Marfan's syndrome

hypotensive; unequal pulses or BP in both arms; acute pulmonary oedema; focal neurological sign of weakness, dysarthria, cranial nerve defects if carotid arteries involved

dizziness, shortness of breath, pleuritic chest pain, haemoptysis; risk factors for thromboembolic disease, such as previous thromboembolism, recent limb trauma, prolonged immobilisation, contraceptive pill use, or underlying malignancy

tachycardia; tachypnoea; hypotension; loud P2; jugular venous distension; right ventricular lift

abdominal and back pain

tachycardia, hypotension, abdominal tenderness; pulsatile abdominal mass; decreased bowel sounds

southeast Asian ethnicity; history of syncope and seizures; family history of sudden cardiac death at young age;[48]Nader A, Massumi A, Cheng J, et al. Inherited arrhythmic disorders: long QT and Brugada syndromes. Tex Heart Inst J. 2007;34(1):67-75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847921 http://www.ncbi.nlm.nih.gov/pubmed/17420796?tool=bestpractice.com recurrent episodes of self-terminating ventricular tachycardia (VT); symptomatic patients have a greater risk of sudden death compared with asymptomatic patients[30]Antzelevitch C, Brugada P, Brugada J, et al. Brugada syndrome: 1992-2002: a historical perspective. J Am Coll Cardiol. 2003 May 21;41(10):1665-71. https://www.sciencedirect.com/science/article/pii/S0735109703003103?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/12767644?tool=bestpractice.com [31]Brugada J, Brugada R, Antzelevitch C, et al. Long-term follow-up of individuals with the electrocardiographic pattern of right bundle-branch block and ST-segment elevation in precordial leads V1 to V3. Circulation. 2002 Jan 1;105(1):73-8. https://www.ahajournals.org/doi/10.1161/hc0102.101354 http://www.ncbi.nlm.nih.gov/pubmed/11772879?tool=bestpractice.com

normal physical examination

history of syncope; cardiac arrest; family history of sudden death at young age; ECG finding of long QT syndrome (LQTS) in family member

examination usually normal; occasionally associated with syndactyly; other associated syndromes such as Jervell and Lange-Nielsen syndrome (hearing loss) and Andersen syndrome (scoliosis and short stature)

young age; family history of sudden death; dizziness; dyspnoea; angina; palpitations; heart failure; pre-syncope

ejection systolic murmur (does not radiate to carotids); murmur louder with Valsalva and isometric exercises; double or triple apical impulse displaced laterally; holosystolic murmur of mitral regurgitation due to systolic anterior motion of mitral leaflet; S4; signs of congestive heart failure (pulmonary rales, lower extremity oedema, jugular venous distension, hepatomegaly)

often young age; may be a family history of heart disease or sudden death; history of palpitations, syncope with exercise

in rare recessive form, skin changes and wooly hair; as disease progresses: signs of right or biventricular heart failure

history rheumatic fever; dyspnoea on exertion; orthopnoea; palpitations; haemoptysis; hoarseness of voice due to compression of left recurrent laryngeal nerve from left atrial enlargement against pulmonary artery

irregularly irregular pulse if in atrial fibrillation; loud S1; murmur: low-pitched diastolic rumble best heard in expiration with patient lying on left side; opening snap; loud P2 if pulmonary hypertension present; signs of congestive heart failure (pulmonary rales, lower extremity oedema, jugular venous distension, hepatomegaly)

fever, weight loss, dyspnoea, palpitation, orthopnoea, paroxysmal nocturnal dyspnoea, presyncope and dizziness, symptoms of embolisation

jugular venous distension with prominent a wave; loud S1; tumour plop in early diastole

dizziness; palpitations; shortness of breath; fatigue; syncope or presyncope; may have known sarcoidosis affecting other organs[50]Kouranos V, Sharma R. Cardiac sarcoidosis: state-of-the-art review. Heart. 2021 Mar 4 [Epub ahead of print]. https://heart.bmj.com/content/early/2021/03/03/heartjnl-2019-316442.long http://www.ncbi.nlm.nih.gov/pubmed/33674355?tool=bestpractice.com

signs for other organ involvement with sarcoidosis (e.g., audible rhonchi on pulmonary exam, non-tender lymphadenopathy, red eyes, skin rash, tenderness and pain on joint exam, hepatomegaly), as disease progresses: signs of heart failure

palpitations, fatigue; risk factors include digoxin toxicity, substance misuse and previous surgery to correct congenital cardiac defects

tachycardia; may detect rales or oedema if congestive heart failure is present

muscle cramping due to ischaemia with upper extremity exercise, often with arm above the head; if arm exercise exceeds the capacity of collateral blood, vertebrobasilar insufficiency can result in dizziness, vertigo, diplopia, syncope, or even dysarthria

difference in BP or pulse measurements in the 2 arms with decreased brachial artery pressure on the affected side; induction of symptoms with exercise and bruit over supraclavicular area

history of implantable cardiac device

dysrhythmia (tachycardia or bradycardia)

amenorrhoea; known pregnancy; previous ectopic pregnancy; prior tubal surgery; pelvic inflammatory disease; IUD usage; abdominal pain; vaginal bleeding

hypotensive; tachycardia; abdominal tenderness and guarding; decreased bowel sounds; cervical motion tenderness; vaginal bleeding

gradual onset; associated with confusion, anxiety, somnolence, palpitations, lethargy; medication history including insulin or sulphonylurea oral hypoglycaemic agents

diaphoretic, tachypnoea, tremor

life-threatening crisis with syncope, nausea, vomiting; or insidious onset, fatigue, weakness, salt craving, dizziness; history of autoimmune disease such as type 1 diabetes, Hashimoto's thyroiditis, or systemic lupus erythematosus

hypotension and/or postural hypotension; mucocutaneous hyperpigmentation; vitiligo

syncope in association with other symptoms of brain stem ischaemia (i.e., diplopia, tinnitus, vertigo, or dysarthria); duration of symptoms associated with transient ischaemic attack (TIA) <24 hours

nystagmus, ataxia, contralateral impairment of pain and temperature, ipsilateral loss of taste and numbness of extremities, completely resolved within 24 hours

history of severe headache, especially with rapid onset (“thunderclap”); loss of consciousness

altered mental status, focal neurological deficit (although neurological exam may be normal), neck pain/stiffness, meningismus, cranial nerve abnormalities

generalised anxiety disorder, panic disorder, somatisation disorder, and major depression can be associated with psychogenic pseudosyncope; conversion disorder can present with apparent syncope; usually young; no known cardiac problems; frequent episodes of recurrent syncope, longer duration of loss of consciousness[15]Alciati A, Shiffer D, Dipaola F, et al. Psychogenic Pseudosyncope: Clinical Features, Diagnosis and Management. J Atr Fibrillation. 2020 Jun-Jul;13(1):2399. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533137 http://www.ncbi.nlm.nih.gov/pubmed/33024500?tool=bestpractice.com

no specific examination findings