Your progress

Saved on this device.

Target exams

Red flags

• Syncope on exertion or while supine — assume a cardiac cause until proven otherwise; investigate with ECG, echocardiography, and ambulatory monitoring, and admit for risk stratification (ESC 2018 high-risk features, PMID 29562304)
• Palpitations preceding syncope, syncope with chest pain or dyspnoea, a family history of sudden death at a young age, or an abnormal ECG (bifascicular block, long QT, Brugada pattern, prior infarct, LVH) — these are the red-flag features of life-threatening arrhythmic syncope
• A systolic murmur in a patient with syncope — think aortic stenosis or hypertrophic cardiomyopathy; echocardiography is mandatory before discharge
• Unexplained syncope or falls in a patient with bifascicular block on ECG (right bundle branch block with left anterior or posterior fascicular block, or left bundle branch block) — the risk of progression to complete heart block is high and pacing is indicated if syncope is unexplained
• Carotid sinus massage producing asystole greater than 3 seconds or a systolic drop greater than 50 mmHg in a patient with recurrent unexplained syncope — this is cardioinhibitory or vasodepressor carotid sinus syndrome and may warrant permanent pacing
• A fall in an anticoagulated older patient with any impact to the head — a subdural haematoma can present subtly over hours to days; a normal GCS does not exclude it, and CT head is indicated if on anticoagulant, if reduced GCS, repeated vomiting, focal neurology, or age over 65 with head impact
• Syncope followed by confusion, tongue-biting, incontinence, or a slow recovery — the diagnosis is seizure, not syncope, and the work-up is different
• Orthostatic hypotension in a patient on multiple antihypertensives or psychotropics — the cause is the drugs, and the treatment is deprescribing, not adding fludrocortisone