EKG
Syncope — EKG-first workup
EKG

Syncope — EKG-first workup

Cardiac vs non-cardiac syncope; what an EKG must rule out.

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◆EKG findings that demand admission

  • •Long QT (drug or congenital)
  • •Brugada pattern (coved ST V1–V3)
  • •Pre-excitation (delta wave) with documented arrhythmia
  • •Bifascicular or trifascicular block
  • •Pathologic Q waves (prior MI) with syncope
  • •Ventricular arrhythmias
  • •HCM (LVH + strain on EKG)

◆Categories of syncope

  • •Reflex (neurally mediated): vasovagal, situational (cough, micturition), carotid sinus — most common, benign
  • •Orthostatic: postural drop in BP — meds (diuretics, α-blockers), volume depletion, autonomic neuropathy
  • •Cardiac: arrhythmia (Brady/Tachy) OR structural (AS, HCM, tamponade, PE, MI) — HIGH risk
  • •Neurologic: rare; seizures, basilar TIA, SAH — usually accompanied by other neuro findings

◆Workup priority

  • •EVERY syncope patient: 12-lead EKG, orthostatic vitals, history (warning signs, exertion, position)
  • •Exertional syncope → ECHO to evaluate for AS, HCM, anomalous coronary
  • •Syncope WITHOUT warning, while supine, or during exertion → cardiac until proven otherwise
  • •San Francisco Syncope Rule (CHESS): CHF, Hct <30%, EKG abnormal, SOB, SBP <90 → admit

High-yield pearls

  • ◆Syncope during exertion = cardiac (AS, HCM, anomalous coronary, arrhythmia) until proven otherwise — get echo + cardiology
  • ◆Vasovagal syncope in young patients with prodrome (nausea, warmth, blurry vision) is the most common cause — reassure, conservative measures
  • ◆Suspected arrhythmia but normal Holter → use 30-day event monitor or implantable loop recorder
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