The syncope patient in clinic

Build the event timeline

Document position, activity, triggers, prodrome, palpitations, duration, witnessed behavior, injury, and recovery. Ask about previous events, cardiac disease, family sudden death, medications, recent fluid loss, and bleeding symptoms.

Check vital signs, orthostatic BP/heart rate when safe, cardiovascular examination, and a 12-lead EKG.^[2]

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Use targeted testing

Choose tests from the history, examination, and EKG. Examples include glucose when hypoglycemia is possible, CBC for suspected bleeding/anemia, and electrolytes/renal function when relevant.

Cardiology can coordinate imaging if structural disease is suspected, exercise evaluation for selected exertional events, or tilt/autonomic testing for selected unresolved cases. Routine broad labs, brain/carotid imaging, or EEG are not indicated for uncomplicated syncope without a specific clinical reason.^[2]

Address likely reflex or orthostatic contributors

For a reassuring assessment, explain the suspected mechanism, review BP-lowering medications and volume status, and teach patients to sit or lie down promptly with warning symptoms. Hydration, salt advice, and medication changes must fit the patient’s HF, kidney disease, hypertension, and other conditions.^[3]

Refer and plan safety

Refer unexplained recurrent events, suspected arrhythmic syncope, abnormal conduction, or structural concerns to cardiology/EP. Selected autonomic or neurologic presentations require other specialist assessment.

Send the event narrative, witness details, EKG, medication list, and prior results. Discuss driving and hazardous activity restrictions according to cause, recurrence risk, and local requirements; do not give one universal restriction for every patient.^{[2], [4]}