An approach to the evaluation and management of syncope in adults

doi:10.1136/bmj.c880

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Steve W Parry, clinical senior lecturer and honorary consultant physician,
Maw Pin Tan, consultant physician

¹Falls and Syncope Service, Royal Victoria Infirmary and Institute for Ageing and Health, Wolfson Centre, Newcastle University, Newcastle upon Tyne NE5 4PL

Correspondence to: S W Parry swparry{at}hotmail.com

Accepted 10 February 2010

Summary points

Syncope is common in all age groups, and it affects 40% of people during their lifetime
Few people with syncope seek medical attention
Neurally mediated syncope, which is benign, is the most common cause
Cardiac syncope as a result of arrhythmias or structural cardiopulmonary disease is more common with increasing age
Cardiac syncope is associated with increased mortality and must be excluded
Brain imaging, carotid Doppler ultrasound, electroencephalography, and chest radiography are not needed in patients with syncope

Cohort and population based studies suggest that around 40% of the adult population has experienced a syncopal episode (usually described as a “faint” or “blackout”),1 2 ^{w1 w2} with women more likely than men to report such an episode.^w1-3 The incidence is higher with advancing age,2 ^w3 and this trend coincides with the increase in prescription of vasoactive drugs and increasing incidence of cardiac arrhythmia in the elderly population. Although comprehensive reviews and guidelines are available for specialists who care for patients referred with syncope,3 4 ^{w4 w5} guidance for the non-specialist is sparse. This review provides guidance for generalists who encounter patients who have had transient loss of consciousness that may be syncopal in nature. It is based on cohort studies, randomised controlled trial evidence, and expert consensus guidelines.

Sources and selection criteria

We searched Medline, PubMed, and Cochrane databases for English articles whose titles included the keywords “syncope”, “vasovagal syncope”, “orthostatic hypotension”, tilt table test”, “cardiac arrhythmia”, or “sudden cardiac death”, with and without the limits “meta-analysis”, “review”, and “randomised controlled trial”. We also consulted recent international guidelines on syncope (including the specialist societies the European Society of Cardiology and the American Heart Association/American College of Cardiology Foundation), and reviewed our personal archives and relevant current textbooks.