‘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