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
Braun, DO, FAAFP,
RFPHM, gave a how-to
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
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,"
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
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.
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Family Medicine Experience (FMX)
Session Navigates the Challenges of Syncopal Episodes