Syncope: A focused approach to the workup and management

Structural heart disease is the most important risk factor for mortality in patients with syncope. A workup that includes a thorough history taking, focused physical examination, and electrocardiography yields a diagnosis in nearly half of cases. Echocardiography is indicated in patients with syncope who have a history of cardiac abnormality, abnormal ECG findings, or unexplained syncope. Tilt-table testing and the implantable loop recorder are useful in patients with recurrent syncope of unclear origin. α-Agonists and selective serotonin reuptake inhibitors are the most effective agents for treating neurocardiogenic syncope. Patients with orthostatic syncope require aggressive hydration and a workup for autonomic insufficiency and, in selected patients, adrenal insufficiency. Implantable cardioverter-defibrillators are indicated in specific forms of cardiogenic syncope. Refer patients with unexplained syncope and suspected structural heart disease and/or negative tilt-table testing and/or abnormal findings on implanted loop recording to a specialist.