Session Navigates the Challenges of Syncopal Episodes

Michael Braun, DO, FAAFP, RFPHM

Michael Braun, DO, FAAFP, RFPHM

Every patient that experiences a syncopal episode should receive an EKG as well as a detailed history and physical exam.

On Thursday morning, Michael Braun, DO, FAAFP, RFPHM, gave a how-to overview regarding evaluating patients who experience syncopal episodes in order to determine cardiac or non-cardiac causes and provided suggestions on preparing diagnostic plans for patients who present with neurocardiogenic forms of syncope.

"Forty percent of the population will have a single episode in their life, and 25 percent of all patients who have a syncopal episode will have another one within a twoyear period," said Braun, chief of inpatient medicine, Department of Family Medicine, and director of the medical wards, Madigan Army Medical Center, Tacoma, Wash., during his presentation "Evaluation of Syncope: The Diagnostic Puzzle."

Patients experiencing syncope can present a diagnostic and treatment challenge to the family physician.

Braun reviewed the cardiac and non-cardiac classifications of syncope, as well as how to evaluate the patient and determine what further testing is required.

Working through an algorithm flowchart, Braun highlighted further tests needed depending on the results of the initial workup, including cardiac imaging and provocative or EKG monitoring tests.

"It's important to note the physical exam and EKG alone will suffice in two-thirds of your diagnoses in most of these patients," he said.

If you suspect heart disease, an echocardiogram, cardiac MRI, cardiac CT, and myocardial perfusion scan, or cardiac catheterization may be indicated. Or if you suspect some other underlying cause, a carotid sinus massage, ATP test, tilt-table testing, exercise treadmill test, or electrophysiology study may be appropriate, especially if you have a patient with a high-risk job.

"If you have a pilot with a syncopal episode, you probably should do a full workup because there could be a greater harm to the general public," he said.

If syncope is expected to reoccur or underlying cardiac issues are at play, Braun said follow up may include EKG monitoring for low-risk patients using a 24- to 48-hour Holter monitor, a 30-day external loop recorder, or an implantable loop recorder that provides a high yield over three years.

"For patients with stroke, an implantable loop recorder can be super helpful," he said.

Braun also reviewed specific arrhythmias that may require inpatient monitoring.

In evaluating risk, he noted that patients with a history including arrhythmia, comorbid conditions, abnormal EKG, family history of sudden death, or older age should be categorized as high-risk and may be appropriately referred to cardiology for further evaluation, or neurology or psychiatry as appropriate.

Patients younger than 50 with no history of cardiovascular disease, a normal EKG, a history consistent with non-cardiac syncope, and an unremarkable cardiovascular exam can be deemed low-risk, and no further workup is required. Treatment can proceed with educating the patient on lifestyle modifications and avoiding triggers.

Braun also encouraged attendees to check their state's requirements regarding driving restrictions for syncope patients.

"You may need to restrict their driving until you know what is going on with them, especially if they are high-risk and you haven't determined what is causing their syncope," he said.