Common Cause Of Syncope Research Articles

SYNCOPE - AN AYURVEDA PERSPECTIVE

In present era increase of Manasika Vikara or mental illnessis the matter of paramount concern in today world. In Ayurvedic literature Murccha is considered as Vyadhi of nervous system which result due to intake of un-wholesome diet and with mind covered with Mansika dosha ie, Rajas and Tamas which ultimately blocks Rak-tha, Rakthavaha srothas, and Sanjavaha srotas and imbalance in three Dosha which disturbs the mind and brings unconsciousness. Syncope is a common chief complaint encountered in the emergency department. Syn-cope is caused by decreased cerebral blood flow leading to transient loss of consciousness and postural tone as-sociated with spontaneous recovery. The cause of syncope ranges from benign to life threatening conditions. The most common causes of syncope seen in the emergency department are due to reflex syncope followed by or-thostatic hypotension and cardiac syncope. Hence this paper is an effort to understand syncope and its Ayurveda perspective.

Vasovagal syncope with asystole.

Although vasovagal episodes are a common cause of syncope, vasovagal syncope can be cardioinhibitory in nature, resulting in a severe heart block or asystole. This case report focuses on a young man with a history of seizures and frequent syncopal episodes who required an extensive clinical workup and treatment for cardioinhibitory syncope.

Pathophysiology of syncope: current concepts and their development.

Syncope is a symptom in which transient loss of consciousness occurs as a consequence of a self-limited, spontaneously terminating period of cerebral hypoperfusion. Many circulatory disturbances (e.g. brady- or tachyarrhythmias, reflex cardioinhibition-vasodepression-hypotension) may trigger a syncope or near-syncope episode, and identifying the cause(s) is often challenging. Some syncope may involve multiple etiologies operating in concert, whereas in other cases multiple syncope events may be due to various differing causes at different times. In this communication, we address the current understanding of the principal contributors to syncope pathophysiology including examination of the manner in which concepts evolved, an overview of factors that constitute consciousness and loss of consciousness, and aspects of neurovascular control and communication that are impacted by cerebral hypoperfusion leading to syncope. Emphasis focuses on 1) current understanding of the way transient systemic hypotension impacts brain blood flow and brain function; 2) the complexity and temporal sequence of vascular, humoral, and cardiac factors that may accompany the most common causes of syncope; 3) the range of circumstances and disease states that may lead to syncope; and 4) clinical features associated with syncope and in particular the reflex syncope syndromes.

Selective anatomical catheter ablation of left atrial ganglionated plexus for vasovagal syncope: Left superior and right anterior ganglionated plexus ablation.

Vasovagal syncope (VVS) is one of the most common causes of syncope. Traditional treatment has not achieved satisfactory results. The purpose of this study was to assess the feasibility and efficacy of selective anatomical catheter ablation of left atrial ganglionated plexus (GP) as a therapeutic strategy for the patients of symptomatic VVS. A total of 70 patients with at least once recurrent syncopal episode of VVS with a positive head-up tilt test were enrolled. They were divided into GP ablation group and control group. Patients in GP ablation group received anatomical catheter ablation of left superior ganglionated plexus (LSGP) and right anterior ganglionated plexus (RAGP). Patients in the control group were guideline-directed conventional therapy. The primary endpoint was VVS recurrences. The secondary endpoint was the recurrence of syncope and prodrome events. There were no statistical differences in clinical characteristics between the ablation group (n=35) and the control group (n=35). Over a follow-up of 12 months, the ablation group had significantly lower syncope recurrence compared with the control group (5.7%vs. 25.7%, p=.02), and the ablation group had significantly lower syncope and prodrome recurrence compared with the control group (11.4%vs. 51.4%, p<.001). In GP ablation, 88.6% of the patients showed significant vagal response during LSGP ablation, and 88.6% of the patients showed significantly increased heart rate during RAGP ablation. For patients with recurrent VVS, selective anatomical catheter ablation of LSGP and RAGP is superior to conventional therapy in reducing syncope recurrence.

A rare cause of recurrent syncope: chemodectoma of left carotid

Syncope is a frequent cause of access to emergency departments. Recurrent syncope may be associated with a transient lock of consciousness. When neurological or cardiological common causes of syncope are excluded, rare causes of syncope, such as solid carotid tumors, should be considered. In this study, we report a rare case of left carotid chemodectoma in a patient with frequent access to the emergency room for syncope in which a thorough differential diagnosis has been performed.

Diagnostic utility and outcomes of inpatient investigations for syncope in a regional setting.

Syncope is a common presentation to the emergency department with a wide spectrum of aetiology. The identification of the underlying cause can be diagnostically challenging, as are the choice of investigations and the decision for inpatient versus outpatient disposition. This study aimed to evaluate the aetiology of syncope as documented, the diagnostic yield of inpatient investigations and outcomes for adult patients admitted for syncope. A single-centred, retrospective cohort study was conducted in adult patients admitted for syncope within a 2-year period. A total of 386 patients were identified after exclusion. Information regarding syncope aetiology, investigations and outcomes were established via chart review of electronic records. The most common cause of syncope was neural-mediated (43%), followed by orthostatic (36.5%) and cardiogenic (20.5%). The investigations performed in order of frequency included: telemetry electrocardiogram (ECG) (75.4%), computed tomography head non-contrast (58.8%), transthoracic echocardiogram (TTE) (20.2%), computed tomography pulmonary angiogram (CTPA) (6.5%), MR brain (3.9%), electroencephalogram (1.3%) and carotid ultrasound (0.3%). Telemetry ECG, TTE and CTPA led to the diagnosis of syncope in a minority of patients only. As a result, 17.5% of patients had a new intervention on discharge, 5.4% were readmitted for syncope and 9.6% of patients died. In the context of the inpatient evaluation of syncope, this study supports the use of telemetry ECG and TTE. Neuroimaging demonstrates a low diagnostic yield for the cause of syncope, but itmay have a role to play in excluding other pathologies. Our study does not support the routine use of CTPA, EEG or carotid ultrasound in the evaluation of syncope.

Improved health-related quality of life after cardioneuroablation in patients with vasovagal syncope.

As the most common cause of syncope, vasovagal syncope (VVS) is mediated by parasympathetic overactivity and/or sympathetic withdrawal. Although catheter ablation of ganglionated plexi or cardioneuroablation has been used to treat VVS, its role in quality of life (QoL) has not been formally evaluated. The aim of this study was to demonstrate if this novel treatment results in improvement QoL of patients with VVS. Twenty-seven consecutive patients (age: 34 ± 14years, 51.8% male) with dominant cardioinhibitory type VVS were prospectively enrolled in the study. After confirmation of > 3s asystole on head-up tilt testing (HUT), all patients underwent cardioneuroablation. ECGs were obtained prior to procedure and at 12-month follow-up visit. HUTs were repeated 1month after cardioneuroablation procedures. QoL was assessed with the use of SF-36, EQ-5D, and EQ VAS questionnaires. ECG, HUT, and QoL data were available in all patients. At 12-month follow-up, heart rate on rest ECG significantly increased (from 74 ± 15 to 84 ± 14bpm, p = 0.003). Repeated HUTs were negative in 23 (85.1%) patients. All of 27 patients remained free of syncope. QoL assessed by SF-36 score significantly improved in postprocedural follow-up (92 ± 9 and 96 ± 11, p = 0.016). Similarly, significant improvements in mobility, self-care, and usual activity domains of EQ-5D were observed (mean scores of 3.0 ± 1.5 and 2.1 ± 1.3, p < 0.001; 1.3 ± 0.9 and 1.2 ± 0.6, p = 0.041; 1.7 ± 1.0 and 1.4 ± 0.8 respectively). EQ-VAS score also improved significantly (39 ± 24 to 77 ± 18, p < 0.001). Our findings suggest that cardioneuroablation may be associated with intermediate term improvement in QoL in patients with VVS.

Diagnostic evaluation of syncope in a tertiary hospital in Metro Manila: a retrospective study

Background: Diagnostic evaluation of syncope is imperative to prevent disability, injury and sudden cardiac death. Work-ups and approach may differ due to geographical factors and the clinical setting where the patient is being managed. This study aims to determine the incidence and evaluation practices for syncope in a single private tertiary center in the Philippines. Methods: A 5-year retrospective study was done wherein records of patients admitted for loss of consciousness were reviewed on domains regarding initial evaluation, specialty referrals, ancillary procedures requested and final diagnosis upon discharge. Results: A total of 572 patients were included. The majority (93%) was referred to cardiology and/or neurology services. Aside from electrocardiogram (ECG), other most common work-ups requested were 2D echocardiogram, brain imaging via Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scan, electroencephalogram (EEG) and 24-hour Holter monitoring- all of which has a low diagnostic yield (≤ 5%). The most common cause of syncope was neurally-mediated syncope (56%), followed by cardiac syncope (18%), orthostatic hypotension (10%), syncope mimics (7.3%), unspecified cause (7%) and psychogenic cause (1.5%). Conclusion: The incidences of syncope types in this southeast Asian population is consistent with previous findings from Western and other Asian countries. The low percent yield of additional diagnostic modalities to syncope work ups strengthens recommendations for a focused initial evaluation (pertinent history-taking, physical examination, electrocardiogram) to reduce unnecessary tests and exhaustion of resources in concordance with the latest international guidelines.

The Diagnosis and Management of Vasovagal Syncope in Pediatric Patients

Vasovagal syncope is the most common cause of syncope in pediatric patients. The present study is aim to provide a comprehensive literature review of the latest advances in the diagnosis and treatment of vasovagal syncope in children. Diagnosis of vasovagal syncope is based on clinical history. For patients with suspected VVS but lack of confident diagnosis after initial assessment, head-up tilt test is helpful. There are four options for treatment of vasovagal syncope: conservative therapy, pharmacologic therapy, pacemaker therapy, and catheter ablation of ganglionated plexi. Conservative therapy (health education, avoidance of triggers, salts and water intake, physical countermeasures and orthostatic training) is recommended for patients with occasional syncope. Pharmacological therapy should be considered for patients with recurrent syncope or for whom conservative therapy has failed. Patients with the predominantly cardioinhibitory response, associated with repeated injury, limited prodromes, and documented asystole may benefit from cardiac pacing. Catheter ablation of ganglionated plexi is a new strategy, its efficacy and safety in pediatric patients should be verified by randomized controlled trials.

Assessment of the patient with syncope

Syncope is a transient loss of consciousness due to cerebral hypoperfusion, characterised by rapid onset, short duration and spontaneous complete recovery. The causes range from self-limiting episodes of reflex syncope to conditions that can precede severe illness or death. GPs often provide the first assessment of patients with syncope and this article aims to guide the assessment of these patients to help identify the cause. This will include exploring the common causes of syncope, history taking, examination, investigations, red flags in syncope and management.

677 UTILITY OF 24 HOUR AMBULATORY BLOOD PRESSURE MONITORING (ABPM) IN PATIENTS WITH ORTHOSTATIC HYPOTENSION (OH) AT SYNCOPE CLINIC

Abstract Introduction OH is a disabling condition resulting from a sustained reduction in blood pressure (&amp;gt;20 systolic or 10 diastolic) within 3 minutes of standing. It is a common cause of syncope. Patients with concurrent hypertension experiencing syncope present a complex management dilemma where a balance must be established between symptom burden and risk of cardiovascular disease. Current guidance on ABPM use in syncope is limited. European society of cardiology syncope guidelines suggest ABPM in patients with ‘autonomic failure’ to assess nocturnal hypertension or drug-induced hypotension. Could this be improved with further explicit criteria on which patients to assess and how to act on results? The objective of this study is to review the use of 24 hour ABPM in OH within a tertiary referral syncope clinic. Method A retrospective analysis was performed electronically for patients with a final diagnosis of OH seen in a syncope clinic between March 2017 and May 2019. Data was collected on comorbidities, medication history, physical mobility, clinic blood pressure, ABPM Results: (if performed) and medication changes. Comparisons were made between patients who had ABPM and those who did not. Statistics were calculated using Fisher’s Exact Test (2 tailed). Results 119 patients had a final diagnosis of OH in the study period. 45 had ABPM, 74 did not. The ABPM group had a significantly higher proportion of diagnosed hypertension (51.1% vs 23% (p = 0.0025)). A similar proportion of patients in both groups had medication changed however the ABPM group were significantly more likely to have antihypertensive therapy added (19.4% vs 1.8% (p = 0.0053)). Conclusion Using 24 hour ABPM in OH patients can aid clinical decision making in the sub-group with hypertension. This can guide the need for alteration/addition of antihypertensive therapy to balance optimum BP control with symptom burden.

Vasoactive Biomarkers in Patients With Vasovagal Syncope During Head-Up Tilt Test: A Case-Control Study.

Background:Vasovagal syncope (VVS) is the most common cause of syncope. Some stages of its pathophysiological mechanisms remain unclear. Vasoactive substances such as nitric oxide metabolites (NOx) and endothelin (ET) may be involved during acute orthostatic stress.Objective:To analyze plasma changes in NOx and ET and heart rate variability (HRV) in the supine positions (T1) and during the head-up tilt test (HUTT) (T2), in patients with VVS (case group) and control group.Methods:Thirty-seven patients (17 in the case group and 20 in the control group), matched for age and sex (mean aged 31.8 years) underwent HUTT with simultaneous HRV recording and venipuncture. Blood samples were collected during phases T1 and T2 and the analysis was performed without knowledge of the HUTT result.Results:In the total sample, there was an increase in NOx values (P = .014), however there was no increase in ET values from phase T1 to phase T2. Patients with VVS tended to increase plasma NOx values (P = .057) and had significantly higher plasma values compared to ET (P = .033) between phases T1 to T2. In the control group, there was no significant change in the values of these vasoactive substances. Regarding HRV, there were a decrease in the component HF (high frequency) and increased of the LF (low frequency)/HF ratio during HUTT.Conclusions:There was an increase in ET during HUTT occurred only in the case group. These patients are more likely to have an imbalance between antagonistic vasoactive biomarkers during orthostatic stress.

Prognostic Value of Biomarkers in Children and Adolescents With Orthostatic Intolerance.

Orthostatic intolerance (OI) refers to a series of symptoms that occur during upright standing, which can be relieved when returned to the supine position. OI is a common cause of syncope in children and adolescents. In recent years, more and more studies have been carried out to assess the prognosis of OI by using biomarkers, among which, flow-mediated vasodilation, left ventricular ejection fraction and fractional shortening, hemodynamic change during head-up tilt test, detection of 24-h urinary sodium excretion, body mass index, midregional pro-adrenomedullin, and erythrocytic H2S producing rate are relatively stable, inexpensive, and easy to obtain. With the help of biomarkers, individualized treatment can be carried out to improve the long-term prognosis of children and adolescents with OI. This article reviews the prognostic value of biomarkers in children and adolescents with OI.

Towards Understanding the Genetic Nature of Vasovagal Syncope.

Syncope, defined as a transient loss of consciousness caused by transient global cerebral hypoperfusion, affects 30–40% of humans during their lifetime. Vasovagal syncope (VVS) is the most common cause of syncope, the etiology of which is still unclear. This review summarizes data on the genetics of VVS, describing the inheritance pattern of the disorder, candidate gene association studies and genome-wide studies. According to this evidence, VVS is a complex disorder, which can be caused by the interplay between genetic factors, whose contribution varies from monogenic Mendelian inheritance to polygenic inherited predisposition, and external factors affecting the monogenic (resulting in incomplete penetrance) and polygenic syncope types.

Lifestyle modification and medical treatment of long QT syndrome

Studies have shown that many manifestations can be observed for patients suffering from long QT syndrome (LQTS), as it is a common cause of syncope and mortality among younger patients, in addition to convulsions. Many management modalities for LQTS have been described in the literature including medical treatment modalities and lifestyle modification approaches. However, evidence regarding the outcomes of these approaches is continuously updating. In this study, we have reviewed findings from the current studies in the literature about the medical treatment and lifestyle modifications for patients suffering from LQTS. Furthermore, studies have shown that β-blockers are effective modalities and should be used at a maximum dose. However, the potential side events should be considered and adequately managed and patient compliance should be maintained along the course of treatment. Implantable cardioverter-defibrillator (ICD) implantation and LCSD were also discussed in the present study with their favorable indications. Additionally, lifestyle modifications were also important and have been reported with favorable events and therefore, these should be considered in such situations. However, evidence regarding some approaches as limiting competitive exercises is still conflicting, indicating the need for future investigations.

S-reflex score: a predictor score of vaso-vagal reflex syncope

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Reflex syncope is one of the most common causes of syncope, usually associated with unspecified triggers and prodromes. The probability of occurrence is higher when concomitant factors coexist whether inherent to individual or related to environment, and changes in conventional tests may prove useful in their diagnosis. Objective Identify predictive factors in the initial investigation in order to establish a predictor score of vasovagal reflex syncope (VVS). Methods Observational and retrospective study, with descriptive analysis and correlation of patients followed in syncope appointment at a Cardiology Center from 1 January 2015 to 31 Novembe 2019. Descriptive analysis on patient characteristics and complementary exams were carried out. The correlation test used between categorical variables was Chi-square and among continuous variables the T-Student test with a significance level of 95%. Independent predictors of VVS were identified through binary logistic regression considering a p = 0.05, with subsequent application of a discriminatory function using the lambda Wilks test to determine the discriminant score of variables under analysis. SPSS 24.0 was used for statistical analysis. Results Identified N694 patients, 52% male, mean age of 63 years. 15.7% of patients with suspected VVS in a first impression. At the end, 22.9% diagnosed with VVS and of these 66% had syncope recurrence. 42% had long prodromes (p = 0.013), 17% with heat prodromes (p = 0.012), in 11.3% the trigger was the meal (p = 0.031), 12.2% suffered trauma (p = 0.07) and 59.7% had ECG with pathological q wave (p = 0.00), thus showing to be independet predictors of VVS. A predictor score of VVS was determined using the formula = -0.761 + (0.529.Long_Prodromes) + (0.721.Heat_Prodromes) + (0.313.Trigger_Meal) + (2,431.ECG_q) - (0.542.Trauma), with a cutoff value of 0.258, specificity of 90.5% with discriminative power of 87%. Conclusion The final diagnosis of VVS was higher than suspicions during initial clinical investigation and 66% of these patients had recurrence. The independent predictors factors of VVS are long prodromes, heat prodromes, meal as a trigger, ECG with q waves and trauma. The S-Reflex score was determined with a good discriminative power with high specificity. Considering clinical variables and conventional exams, this score could be useful to guide the strategy for syncope patients after the first evaluation to a more cost-effective strategy.

Midodrine treatment in children with recurrent vasovagal syncope.

Vasovagal syncope is the most common cause of syncope in childhood and its treatment is not at a satisfactory level yet. We aimed to investigate patients who were diagnosed with vasovagal syncope, did not benefit from conventional treatment, received midodrine treatment, and to evaluate their response to midodrine treatment. Files of 24 patients who were diagnosed with recurrent vasovagal syncope, did not benefit from non-pharmacological treatments, and received midodrine treatment during June 2017-October 2019 were retrospectively analysed. In total, 24 patients received a treatment dose of midodrine at 5 mg/day (2.5 mg BID) included in the study. The mean number of syncope was 5.75 ± 2.67 prior to treatment. Following treatment, the mean number of syncope was 0.42 ± 0.89. It was observed that syncope episodes did not recur in 17 patients, but it recurred in 4 out of 7 patients in the first 3 months of the treatment and did not recur in the following months. The episodes improved in two patients with an increase in the treatment dose, but the syncope episodes continued in only one patient. It was concluded that midodrine treatment was effective and safe in adolescents with recurrent vasovagal syncope.

Etiology and prognosis of patients with unexplained syncope and mid-range left ventricular dysfunction

Syncope in patients with mid-range left ventricular ejection fraction (LVEF) can be due to potentially serious arrhythmic causes. However, there is no clear consensus on the best way to manage these patients. The objectives of this study were to determine the causes of syncope and assess the diagnostic yield and safety of a stepwise workup protocol in this population. This was a prospective observational study. A stepwise workup protocol was applied to patients with LVEF 35%-50% and unexplained syncope after the initial assessment (step 1). One hundred four patients were included {median age 75.6 years; (interquartile range [IQR] 67.6-81.2 years); median LVEF 45% (IQR 40%-48%); median follow-up 2.0 years (IQR 0.7-3.3 years). In 71 patients (68.3%), a diagnosis was reached: 55 (77.5%) in step 2 (hospital admission and electrophysiology study) and 16 (36.5%) in step 3 (implantable cardiac monitor). Arrhythmic causes were the most common etiology (45.2% auriculoventricular block and 9.6% ventricular tachycardia). Sixty patients (57.7%) required the implantation of a cardiac device and 11 had a defibrillation function. Patients diagnosed in step 3 had a higher global risk of recurrence of syncope (hazard ratio 6.5; 95% confidence interval 2.3-18.0). The mortality rate was 8.1 per 100 person-years, and the sudden or unknown death rate was 0.9 per 100 person-years. In patients with mid-range left ventricular dysfunction and syncope of unknown cause, a systematic diagnostic strategy based on electrophysiology study and/or implantable cardiac monitor implantation allows a diagnosis to be reached in a high proportion of cases and guides the treatment. Arrhythmia is the most common cause of syncope in this population, particularly auriculoventricular block.

Neurohormones in the Pathophysiology of Vasovagal Syncope in Adults.

Vasovagal syncope (VVS) is the most common cause of syncope across all age groups. Nonetheless, despite its clinical importance and considerable research effort over many years, the pathophysiology of VVS remains incompletely understood. In this regard, numerous studies have been undertaken in an attempt to improve insight into the evolution of VVS episodes and many of these studies have examined neurohormonal changes that occur during the progression of VVS events primarily using the head-up tilt table testing model. In this regard, the most consistent finding is a marked increase in epinephrine (Epi) spillover into the circulation beginning at an early stage as VVS evolves. Reported alterations of circulating norepinephrine (NE), on the other hand, have been more variable. Plasma concentrations of other vasoactive agents have been reported to exhibit more variable changes during a VVS event, and for the most part change somewhat later, but in some instances the changes are quite marked. The neurohormones that have drawn the most attention include arginine vasopressin [AVP], adrenomedullin, to a lesser extent brain and atrial natriuretic peptides (BNP, ANP), opioids, endothelin-1 (ET-1) and serotonin. However, whether some or all of these diverse agents contribute directly to VVS pathophysiology or are principally a compensatory response to an evolving hemodynamic crisis is as yet uncertain. The goal of this communication is to summarize key reported neurohumoral findings in VVS, and endeavor to ascertain how they may contribute to observed hemodynamic alterations during VVS.

Abstract 367: Are We Over-utilizing Echocardiogram for the Evaluation of Syncope Patients?

Background: Syncope is one of the most common reasons for emergency department visits. The most common causes of syncope include vasovagal, orthostatic, neurogenic and cardiogenic. In some cases, history and physical examination can point towards a specific cause. While in most cases, history and physical alone are insufficient to indicate an obvious etiology. Patients with cardiogenic syncope have an increased rate of all-cause mortality as well as mortality associated with cardiovascular events. The risk of missing these serious conditions often results in low-risk patients being admitted for further workup and undergoing extensive investigation including a transthoracic echocardiogram (TTE). However, the utility of such testing including TTE in patients with a negative initial evaluation with history, physical exam and ECG is uncertain. The aim of this study was to assess the utility of TTE in the evaluation of patients admitted with syncope with an initial negative evaluation Methods: It is a retrospective study. Data was collected from all the patients admitted to the hospital for the workup of syncope from January to October 2019. Baseline characteristics including age, sex and ethnicity were collected for each patient. Data was also collected in regard to their significant cardiac past medical and family history. History of present illness and physical examination at the time of admission was noted. Patients were divided into two groups based on if the medical evaluation indicated a cardiogenic etiology. Cardiac testing data including EKG and TTE were included in the analysis. Abnormal EKG was defined by the presence of bradycardia, arrhythmia, QT prolongation, bundle branch blocks, heart blocks and left ventricular hypertrophy. Positive TTE findings were defined as low ejection fraction, significant left ventricular outflow tract obstruction, significant valvular abnormalities, wall motion abnormality and presence of pericardial effusion. Collected data were analyzed using Chi-square test and multiple linear regression. Results: The mean age of the study group was 72 years with 45% of males. Out of the total of 93 patients included in the study, 57(61%) patients had a TTE done. Out of this only 10(17%) patients had positive TTE. Only 2 patients with positive TTE had a negative EKG. In these two patients, the history was, however suspicious for cardiogenic syncope. A significant association of positive TTE findings with abnormal EKG (p-value: 0.003) was found. The odds of having a positive TTE finding when the EKG was negative was only 6%. These results remained significant with multiple linear regression analyses. Conclusions: TTE is being overutilized in the evaluation of patients presenting with syncope to rule out cardiac etiology. A thorough history and complete physical examination along with the basic cardiac testing including EKG can help reduce the overutilization