Current evaluation and management of syncope.

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Case: A 75-year-old woman was referred for recurrent syncope. Over the past 12 months, she had had 10 episodes of brief (less than 1 minute) loss of consciousness with rapid recovery. She has known coronary artery disease and underwent coronary artery bypass grafting 2 years ago. She had diabetes mellitus that was well controlled with insulin. Her physical examination was normal, including orthostatic blood pressures. She has been admitted several times to different hospitals for the evaluation of recurrent syncope. Electrocardiograms have shown left bundle-branch block. Holter monitoring, electroencephalograms, and head computed tomography scans have been negative. Neurology consult believed that there was not a neurological cause for her loss of consciousness. A thallium stress test was negative for ischemia, and an echocardiogram showed normal ventricular function. Syncope is a sudden temporary loss of consciousness associated with a loss of postural tone and spontaneous recovery not requiring electrical or chemical cardioversion. Syncope has a large differential diagnosis, is difficult to evaluate, and can be disabling. There are subsets of syncopal patients with a high risk of sudden death. The central issues in the evaluation of syncope are establishing the cause of syncope, deciding whether the patient needs to be admitted, and treating the causes of syncope effectively to reduce recurrences and potentially improve patient outcomes. The first issue to resolve is whether the patient had syncope. Dizziness, presyncope, drop attacks, and vertigo are easily distinguished from syncope because these symptoms do not lead to loss of consciousness. Seizures, however, are often difficult to distinguish from syncope. Features useful in separating seizure and syncope are precipitants, prodromal symptoms, complaints during the spell, and symptoms after the episode. Loss of consciousness precipitated by pain or occurring after exercise, micturition, defecation, and stressful events is generally due to syncope, whereas aura may precede …