Syncope toolkit

Syncope is very common and will affect 42% of people during their lifetime

Syncope of unknown origin case history

History

A 59 year old man consults with you describing a history of recurrent syncope. He reports seven episodes of syncope in the previous 12 months with rapid onset, no warning signs and no apparent triggers. He has no significant past medical history and takes no medications.

Examination

Cardiovascular examination is normal.

What would you do next?

You should advise him that he must not drive, and he must notify the DVLA. He requires further evaluation with an ECG (which is normal). He should also be referred to a cardiologist.

Outcome

His cardiologist organises further tests including carotid sinus massage, tilt table testing and echocardiogram which are all normal. He receives an insertable cardiac monitor (ICM), and 9 months later experiences a syncopal episode associated with a recorded 21 second asystolic pause. His diagnosis is asystolic vasovagal syncope. Lifestyle changes do not improve his symptoms as he has no warning an no clear triggers. He subsequently has a pacemaker fitted with no further episodes of syncope.

Learning Points

In cases of recurrent syncope with no evidence of structural heart disease on initial assessment and normal ECG, ICMs can provide evidence of the underlying cause.