![]() ![]() Nurse or technician to monitor blood pressure and pulse, physician to perform the procedure Intravenous access, pulse oximeter, electrocardiograph Recent (within past three months) myocardial infarction, transient ischemic attack, or stroke presence of ventricular fibrillation, ventricular tachycardia, or carotid bruits History of syncope after head turning, shaving, or while wearing a tight collar older patients with unexplained presyncope or falls negative cardiovascular and neurologic investigations Volume depletion medications illegal drugs or alcohol diabetes or amyloid neuropathy Multiple system atrophy pure autonomic failure Parkinson’s disease Sinus node dysfunction second- or third-degree heart block ventricular tachycardia implanted device malfunction (e.g., pacemaker, implantable cardioverter-defibrillator) Valvular disease, particularly aortic or mitral stenosis acute cardiac syndromes or ischemia pulmonary embolism or hypertension acute aortic dissection hypertrophic cardiomyopathy pericardial disease or tamponade atrial myxoma Glossopharyngeal and trigeminal neuralgia Situational (e.g., coughing, sneezing, defecating, micturition, postmicturition) The use of tests such as head computed tomography, magnetic resonance imaging, carotid and transcranial ultrasonography, and electroencephalography to detect cerebrovascular causes of syncope should be reserved for those few patients with syncope whose history suggests a neurologic event or who have focal neurologic signs or symptoms. When structural heart disease is excluded, tests for neurogenic reflex-mediated syncope, such as head-up tilt-table testing and carotid sinus massage, should be performed. Older patients and those with underlying organic heart disease or abnormal electrocardiograms generally will need additional cardiac evaluation, which may include prolonged electrocardiographic monitoring, echocardiography, and exercise stress testing. Additional testing should be based on the initial clinical evaluation. ![]() The evaluation of syncope begins with a careful history, physical examination, and electrocardiography. A cardiac cause of syncope is associated with significantly higher rates of morbidity and mortality than other causes. Syncope can be classified into four categories: reflex mediated, cardiac, orthostatic, and cerebrovascular. Syncope must be carefully differentiated from other conditions that may cause a loss of consciousness or falling. Though relatively common, syncope is a complex presenting symptom defined by a transient loss of consciousness, usually accompanied by falling, and with spontaneous recovery.
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