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CLINICAL GUIDELINE: Diagnosing Syncope: Part 1: Value of History, Physical Examination, and Electrocardiography

Mark Linzer, MD; Eric H. Yang, BS; N.A. Mark Estes III, MD; Paul Wang, MD; Vicken R. Vorperian, MD; and Wishwa N. Kapoor, MD, MPH
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For the Clinical Efficacy Assessment Project of the American College of Physicians* For author affiliations and current author addresses, see end of text. *For members of the Clinical Efficacy Assessment Project, see Appendix. Note: The Clinical Efficacy Assessment Project (CEAP) of the American College of Physicians is designed to evaluate and inform College members and others about the safety and efficacy of diagnostic and therapeutic methods. Acknowledgments: The authors thank Dr. Edward L.C. Pritchett for comments on the cardiologic sections of the manuscript; Dr. Benjamin Eidelman for comments on the neurologic sections; Dr. David Katz for comments on an earlier version of the manuscript; Thomas Havighurst, MS, for statistical analysis; and Cindy Gilles for secretarial assistance. Requests for Reprints: Mark Linzer, MD, University of Wisconsin School of Medicine, Department of Medicine, J5/210 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-2454. Current Author Addresses: Dr. Linzer: University of Wisconsin School of Medicine, Department of Medicine, J5/210 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;126(12):989-996. doi:10.7326/0003-4819-126-12-199706150-00012
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Purpose: To review the literature on diagnostic testing in syncope and provide recommendations for a comprehensive, cost-effective approach to establishing its cause.

Data Sources: Studies were identified through a MEDLINE search (1980 to present) and a manual review of bibliographies of identified articles.

Study Selection: Papers were eligible if they addressed diagnostic testing in syncope or near syncope and reported results for at least 10 patients.

Data Extraction: The usefulness of tests was assessed by calculating diagnostic yield: the number of patients with diagnostically positive test results divided by the number of patients tested or, in the case of monitoring studies, the sum of true-positive and true-negative test results divided by the number of patients tested.

Data Synthesis: Despite the absence of a diagnostic gold standard and the paucity of data from randomized trials, several points emerge. First, history, physical examination, and electrocardiography are the core of the syncope workup (combined diagnostic yield, 50%). Second, neurologic testing is rarely helpful unless additional neurologic signs or symptoms are present (diagnostic yield of electroencephalography, computed tomography, and Doppler ultrasonography, 2% to 6%). Third, patients in whom heart disease is known or suspected or those with exertional syncope are at higher risk for adverse outcomes and should have cardiac testing, including echocardiography, stress testing, Holter monitoring, or intracardiac electrophysiologic studies, alone or in combination (diagnostic yields, 5% to 35%). Fourth, syncope in the elderly often results from polypharmacy and abnormal physiologic responses to daily events. Fifth, long-term loop electrocardiography (diagnostic yield, 25% to 35%) and tilt testing (diagnostic yield ≤ 60%) are most useful in patients with recurrent syncope in whom heart disease is not suspected. Sixth, psychiatric evaluation can detect mental disorders associated with syncope in up to 25% of cases. Seventh, hospitalization may be indicated for patients at high risk for cardiac syncope (those with an abnormal electrocardiogram, organic heart disease, chest pain, history of arrhythmia, age >70 years) or with acute neurologic signs.

Conclusions: Many tests for syncope have a low diagnostic yield. A careful history, physical examination, and electrocardiography will provide a diagnosis or determine whether diagnostic testing is necessary in most patients.


Grahic Jump Location
Figure 1.
Algorithm for diagnosing syncope.

*Carotid massage can be performed in an office setting only in the absence of bruits, ventricular tachycardia, recent stroke, or recent myocardial infarction. Carotid hypersensitivity should be diagnosed only if clinical history is suggestive and massage is diagnostically positive (asystole ≥ 3 seconds, hypertension, or both). † May be replaced by inpatient telemetry if there is concern about serious arrhythmia. Echo = echocardiography; OHD = organic heart disease.

Grahic Jump Location




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