Mount Carmel Health Partners Clinical Guidelines Syncope | Page 3

(Evaluation continued)
Any patient presenting with syncope, pre-syncope, heart failure, atrial fibrillation, or a need for surgery with a pacemaker or ICD
in situ who is being admitted and any patient with a pacemaker or ICD in situ who is being sent home, unless the etiology is obvious
(orthostatic hypotension, hypoglycemia, etc.), should have the device interrogated. For patients with Medtronic or Boston Scientific
devices, this should be done prior to leaving the ED via the Carelink Express or Latitude Consult system. For St. Jude or Biotronik
Devices, have the vendor rep or device staff do it the next day.
Patients with one or more should be considered for admission (Rose Clinical Decision Rule – BRACES):
B — BNP >300 Bradycardia <50 bpm
R — Rectal exam, positive for fecal occult blood
A — Anemia (Hgb <9 g/dl)
C — Chest pain associated with syncope
E — ECG, Q wave (not lead III)
S — Sp0₂<94% on room air
If signs or symptoms of heart failure are present, both echocardiography and an evaluation for ischemia (e.g., stress testing) should
be considered.
If the clinical presentation is atypical for NCS/OH (for example, with minimal or no prodrome, occurrence while seated or supine,
occurrence during exercise, or associated with significant injuries), or if the patient has a family history of early sudden death, or if
the patient does not respond to appropriate initial therapy, echocardiography and ambulatory ECG should be considered. Note that
24-hour Holter monitoring has a very low yield and is not generally recommended for this indication; if ambulatory ECG is pursued, it
should be with a 10- to 14-day patch monitor, 30-day looping event recorder, or implantable loop recorder, depending on the
frequency of clinical events. Tilt testing can be considered, but has poor sensitivity and specificity and should not generally be a first
line test.
If the clinical presentation is compatible with seizure (focal neurological signs, auras, tongue-biting, loss of bowel or bladder function,
witnessed convulsions, prolonged postictal phase), then evaluation for seizure should occur as well. However, note that convulsions
are not uncommon during genuine syncope; furthermore, true syncope and true seizure can co-exist in the same patient.
Treatment
Treatment is based upon the underlying cause of syncope and is directed at preventing recurrence and/or, in some cases, death.
Medication and simple lifestyle modifications can often prevent reflex-related syncope events. If a cardiovascular or neurological
cause is to blame, the provider should consider a referral to a specialist (see Table Two) to diagnose and treat the suspected
condition.
Follow Up
If a patient is not considered high risk, discharge and close interval follow up with a PCP or specialist is recommended.
Table One: All patients with syncope require an ECG evaluation to look for signs of the following:
Ischemia or MI Aortic stenosis
Arrhythmias Left ventricular hypertrophy; hypertrophic cardiomyopathy
Prolonged QT Wolff-Parkinson-White syndrome
Pre-excitation syndrome Brugada syndrome (RBBB, ST elevation in V1-V3)
Pulmonary embolus
- tachycardia
- right strain or RBBB
- T wave inversion in V1-V4
- S1Q3T3 Pericarditis; diffuse ST elevation or electrical alternans with
pericardial tamponade; low voltage QRS complexes
Syncope - 3