Download Features suggestive of a neurally - mediated cause

Pathway for Diagnosis / Referral of Adults with Dizziness and/or
Syncope presenting in Primary Care
Did the patient have a spontaneous loss of
consciousness and/or dizziness?
YES
or
UNCERTAIN
NO
Is there a family history of Sudden
Cardiac Death under 40yrs, Hypertrophic
Cardiomyopathy or Channelopathies?
NO
Still Requires ECG
Is there a history of brain injury
or feature strongly suggestive
of epilepsy and normal ECG?
Consider falls, TIA, CVA, drug
misuse etc
YES
ECG &
REFER CARDIOLOGY
Is there evidence of significant
structural heart disease or
abnormal ECG
NO
Cardiac exam / CXR
Features strongly suggestive of
vasovagal syncope
Reassure
Recurrent Events
YES
YES
Suggest Neurology Referral
Open access memo or tape*
and / or Echo
REFER CARDIOLOGY
NO
Features suggestive of
orthostatic hypotension
Neither vagal, nor orthostatic
Review medications
Open access memo or tape *
REFER CARDIOLOGY
* Open access memo or tape
If available locally, an aid to the correct device
Is given in the accompanying guidelines
ECN DS FINAL 090907 6 pages
Note: Recurrent worrying symptoms
unexplained by this pathway: Cardiology
1
advice can be sought
Management of Adults with
Dizziness and/or Syncope presenting in Primary Care
1. Initial Evaluation
 History
3 Key Questions to answer during initial evaluation:
A. Is loss of consciousness due to syncope?
 Features that suggest a non-syncopal attack:
 Confusion after the attack for more than 5 minutes (seizure) - some caution in elderly patients where
recovery may be more protracted
 Prolonged (>15 sec) tonic-clonic movement starting at the onset of the attack (seizure)
 Associated with vertigo, dysarthria, diplopia (TIA)
 TIAs in general do not cause drop attacks and syncope
B. Are there clinical features suggestive of diagnosis?

See Aids to Diagnosis below
C. Is heart disease present or absent?
 Aortic Stenosis
 Left Ventricular systolic dysfunction
 Examination
 Supine and Erect BP
 ECG
ECN DS FINAL 090907 6 pages
2
2. Aids in Diagnosis:
Syncope
Is a sudden but brief loss of consciousness that is caused by inadequate blood supply to the brain. Recovery is
spontaneous and rapidly complete.
Syncope is common, disabling and possibly associated with sudden cardiac death.
Vasovagal Syncope

Precipitating event such as fear, severe pain, emotional stress, instrumentation or prolonged standing are associated
with typical prodromal symptoms (although prodrome is not always present, the precipitating factors still have diagnostic
significance)
Situational Syncope

If syncope occurs during or immediately after urination, defecation,
cough or swallowing
Orthostatic Syncope

If there is documentation of orthostatic hypotension (decrease of SBP=20mmHg or to <90mmHg) associated
with syncope or presyncope
Features strongly suggestive of Reflex Syncope

Occurs when standing, extreme pallor, random limb jerks, always collapse to floor, quick recovery
Syncope due to Cardiac Ischaemia

If symptoms present with ECG evidence of acute ischaemia with or without
myocardial infarction
Syncope due to Cardiac Arrhythmia
 If ECG changes showing :
 Sinus bradycardia <40bpm or repetitive sinoatrial blocks or sinus pause >3 seconds
 Atrioventricular block (2nd degree, Mobitz 11, or 3rd degree atrioventricular block )
Alternating left and right bundle branch
 Pacemaker malfunction with cardiac pauses
 Rapid paroxysmal supraventricular tachycardia or ventricular tachycardia
ECN DS FINAL 090907 6 pages
3
Vertigo
Is a hallucination of movement of the environment about the patient, or of the patient with respect to the environment. It is
not synonymous with dizziness. It may be central - due to a disorder of the brainstem or the cerebellum - or peripheral - due
to a disorder in the inner ear or the Vlllth cranial nerve. Always would suggest ENT review prior to cardiac review unless
associated with palpitations or chest pain
Significant Structural Damage
This includes Previous Myocardial Infarction, Heart Failure, Cardiomyopathy, Valvular Heart Disease
Features suggestive of heart rhythm abnormality
This includes sudden unexplained syncope during exercise/exertion, excitement, stress or startle.
Features suggestive of a cardiac cause





Symptoms when supine
During exertion
Preceded by palpitations
Presence of severe heart disease
ECG abnormalities:
o Wide QRS (>0.12 sec)
o AV conduction abnormalities
o Sinus bradycardia less than 50 bpm or pause of greater than 2 seconds during the day, or 3 seconds at night
o Long QT interval
Features suggestive of Epilepsy

Tonic/Clonic Movement, cyanosis, incontinence, lateral tongue biting, prolonged post ictal confusion
Features suggestive of a neurally - mediated cause






After sudden unexpected unpleasant sight, sound or smell
Prolonged standing at attention or crowded warm place
Nausea, vomiting associated with syncope
Within one hour of a meal
After exertion
Temporal relationship with start of medication or changes of dosage
ECN DS FINAL 090907 6 pages
4
Electrocardiograms that require urgent attention

Bradycardia: <40bpm) or pauses >3secs

Mobitz 11, 2nd, 3rd degree AV block

Altemating RBBB LBBB

Rapid Supraventricular Tachycardia

Ventricular Tachycardia

Cardiac ischaemia

Myocardial Infarction

WPW

Long QT

Brugada
Prognostic Stratification


Poor prognosis:
o structural heart disease:- This is the most important predictor of total mortality and sudden death in patients with
syncope, independent of the cause of the syncope
Excellent prognosis:
o young, healthy, normal ECG
o neurally mediated syncope
o orthostatic hypotension
o unexplained syncope
ECN DS FINAL 090907 6 pages
5
Cardiomemo or 24 hour tape?

A cardiomemo is a patient activated event recording device that is generally provided for 5 to 7 days. It is helpful for
infrequent symptoms and is recommended for patients who have symptoms less than once a day but more frequent than
once a fortnight

A 24 hours tape allows continuous heart rhythm monitoring for 24 hours. It is indicated where there are symptoms on a
daily, or near daily, basis
ECN DS FINAL 090907 6 pages
6