Syncope Evaluation Medical Slides

Present the major tools with performance data: San Francisco Syncope Rule (CHESS: CHF, Hct<30, abnormal ECG, SOB, SBP<90) — sensitivity 96% but low specificity for serious outcomes. Canadian Syncope Risk Score (CSRS) — validated for 30-day serious events, incorporates ED diagnosis and troponin, outperforms SFSR. EGSYS score — best for identifying cardiac syncope specifically. ESC 2018 algorithm — gold standard, emphasizes that a thorough history alone can identify the cause in up to 50% of cases. No tool is perfect — clinical judgment remains essential.

Present the high-risk features from ESC 2018: syncope during exertion (aortic stenosis, HCM, anomalous coronary), in supine position (arrhythmia), preceded by palpitations (VT, SVT with rapid rate), with chest pain (ACS, PE, aortic dissection). ECG red flags: QTc >480 ms, Brugada pattern, WPW, bifascicular block, Q-waves suggesting prior MI, high-degree AV block. History red flags: family history of SCD <40, known structural heart disease, new-onset heart failure. Any of these warrant cardiac monitoring and urgent workup — 1-year mortality in cardiac syncope is 18-33% vs 6% for non-cardiac.

Present the ESC risk-stratified approach: Low risk (discharge) — young patient, typical vasovagal features (prolonged standing, prodrome, crowded/hot environment), normal ECG, normal vitals, no cardiac history. High risk (admit) — any cardiac red flag, abnormal ECG, severe injury from syncope, persistent abnormal vitals, significant comorbidities. Intermediate risk — consider ED observation unit (6-24 hours) with telemetry monitoring. Emphasize that unexplained syncope in patients >60 or with cardiac disease warrants admission. All discharged patients need clear return precautions and outpatient follow-up plan.