Syncope — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 69-year-old man with previous myocardial infarction and heart failure loses consciousness while walking up a hill and recovers fully within a minute. He had no warning. In the emergency department (ED) his blood pressure (BP) is 118/72 mmHg and the electrocardiogram (ECG) shows sinus rhythm and is otherwise normal, with no acute ischaemic changes.^[1]

1. Give the 2018 European Society of Cardiology (ESC) definition of syncope. (1)^[1]
2. List three items that make up the initial syncope evaluation in ESC 2018. (1)^[1]
3. Identify the features in this scenario that ESC 2018 Table 6 lists as high-risk, stating whether each is major or minor. (3)^[1]
4. State the ESC 2018 recommendation for disposition of a patient with high-risk features, with its class and level, and the monitoring that ESC 2018 indicates for high-risk patients. (2)^[1]
5. State the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) 2017 recommendation on hospital evaluation, with its class of recommendation (COR) and level of evidence (LOE), and name the key determinant for in-hospital management in that guideline. (2)^[2]
6. State how each guideline grades the use of risk stratification scores. (1)^[1][2]

Model answers — SAQ 1

1. Transient loss of consciousness (TLOC) due to cerebral hypoperfusion, characterised by a rapid onset, short duration and spontaneous complete recovery (1 mark).^[1]
2. Careful history (with eyewitness accounts), physical examination including supine and standing BP, and an ECG (1 mark for all three).^[1]
3. Syncope during exertion: major high-risk feature of the syncopal event (1 mark).^[1] Severe structural or coronary artery disease (heart failure, low left ventricular ejection fraction [LVEF] or previous myocardial infarction): major high-risk feature of the past history (1 mark).^[1] No warning symptoms: a minor feature, high-risk only if associated with structural heart disease or abnormal ECG; he has structural heart disease, so it counts as high-risk (1 mark).^[1]
4. ESC 2018 recommends that patients with high-risk features receive an early intensive and prompt evaluation in a syncope unit or in an ED observation unit (if available), or are hospitalised (Class I, Level B) (1 mark).^[1] ESC 2018 indicates immediate in-hospital monitoring, in bed or by telemetry, in high-risk patients defined in Table 6 (Class I, Level C) (1 mark).^[1]
5. ACC/AHA/HRS 2017 recommends hospital evaluation and treatment for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation (COR I, LOE B-NR) (1 mark).^[2] ACC/AHA/HRS 2017 makes the presence of at least one serious medical condition (its Table 7) the key determinant for further in-hospital management; risk factors and risk scores are not primary determinants for admission (1 mark).^[2]
6. ESC 2018: risk stratification scores may be considered in the ED (Class IIb, Level B); ACC/AHA/HRS 2017: their use may be reasonable (COR IIb, LOE B-NR) (1 mark for both).^[1][2]

SAQ 2 (10 marks)

Practice scenario. A 78-year-old woman with Parkinson’s disease faints twice after standing up. She takes a dopaminergic drug for her Parkinson’s disease and no antihypertensive agents, nitrates, diuretics or neuroleptic antidepressants. Supine BP is 136/80 mmHg; after 2 minutes of active standing it is 102/68 mmHg, with her usual light-headedness. Her heart rate rises by 6 beats per minute (b.p.m.).^[1]

1. Give the ACC/AHA/HRS 2017 definition of orthostatic hypotension (OH) and of classic OH. (2)^[2]
2. Give the ESC 2018 criteria for an abnormal BP fall on active standing, and state what ESC 2018 adds to the 2011 consensus. (2)^[1]
3. Interpret her heart rate response using ESC 2018. (1)^[1]
4. List four measures from the ESC 2018 OH recommendation table other than midodrine and fludrocortisone, with class and level. (2)^[1]
5. Name two drugs from the ESC 2018 OH table with the doses ESC 2018 gives. (2)^[1]
6. Which ACC/AHA/HRS 2017 recommendation on neurogenic OH carries COR I? (1)^[2]

Model answers — SAQ 2

1. OH: a drop in systolic BP of ≥20 mm Hg or diastolic BP of ≥10 mm Hg with assumption of an upright posture (1 mark).^[2] Classic OH: a sustained reduction of systolic BP of ≥20 mm Hg or diastolic BP of ≥10 mm Hg within 3 min of assuming upright posture (1 mark).^[2]
2. A progressive and sustained fall in systolic BP from baseline ≥20 mmHg or diastolic BP ≥10 mmHg, or a decrease in systolic BP to <90 mmHg (1 mark).^[1] ESC 2018 adds the absolute 90 mmHg systolic threshold to the 2011 consensus, useful especially with supine BP below 110 mmHg (1 mark).^[1]
3. Her systolic fall of 34 mmHg meets the criterion; ESC 2018 states that the orthostatic heart rate increase is blunted or absent (usually not >10 b.p.m.) in neurogenic OH, which fits a rise of 6 b.p.m. (1 mark).^[1]
4. Any four (0.5 mark each): explanation of the diagnosis, reassurance, explanation of the risk of recurrence and avoidance of triggers and situations (Class I, Level C); adequate hydration and salt intake (Class I, Level C); modification or discontinuation of hypotensive drugs (Class IIa, Level B); isometric counter-pressure manoeuvres (Class IIa, Level C); abdominal binders and/or support stockings to reduce venous pooling (Class IIa, Level B); head-up tilt sleeping (>10 degrees) to increase fluid volume (Class IIa, Level C).^[1] Currency note (no extra mark): for orthostatic hypotension in persons with supine hypertension, the 2024 ESC hypertension row recommends non-pharmacological approaches as the first-line treatment and switching BP-lowering medications that worsen orthostatic hypotension to an alternative BP-lowering therapy, not simply de-intensifying therapy (Class I, Level A); its drug advice concerns BP-lowering medications only, and for those medications in that group it replaces the older ESC 2018 drug-modification row.^[8][1] ESC 2018 counts dopaminergic drugs among the agents that lower BP.^[1] ESC 2024, by contrast, separates BP-lowering medications from other drugs that can reduce BP (Recommendation Table 23), and its OH row concerns switching BP-lowering medications to an alternative BP-lowering therapy and does not name dopaminergic drugs.^[8] Of the agents that ESC 2018 lists, she takes only a dopaminergic drug, so the switching advice in the ESC 2024 OH row (Recommendation Table 24) does not apply to her.^[1][8] For her dopaminergic drug, two ESC 2018 rows that cover it are given as current among the ESC guidelines checked for this topic: the OH drug-modification row and the row on modifying or discontinuing possible culprit medications, particularly hypotensive drugs and psychotropic drugs, in older patients with syncope or unexplained fall (both Class IIa, Level B).^[1] ACC/AHA/HRS 2017 adds that many symptomatic treatments for neurodegenerative disease will increase the risk of syncope due to worsening OH, and that their selection needs to be balanced against the increased morbidity of not treating the symptoms of the neurodegenerative disease.^[2] For very old or frail patients with hypertension, see also the ESC 2024 deprescription row: if BP drops with progressing frailty, deprescription of BP-lowering medications and other drugs that can reduce BP may be considered (Class IIb, Level C).^[8]
5. Midodrine should be considered if symptoms persist (Class IIa, Level B); ESC 2018 text gives 2.5–10 mg three times daily (t.i.d.) (1 mark).^[1] Fludrocortisone should be considered if symptoms persist (Class IIa, Level C); ESC 2018 text gives 0.1–0.3 mg once daily (1 mark).^[1]
6. Acute water ingestion is recommended in patients with syncope caused by neurogenic OH for occasional, temporary relief (COR I, LOE B-R) (1 mark).^[2]