A Practical Approach to Syncope HT @amalmattu


I came across this article in the Canadian Journal of Cardiology (doesn't everyone read it? No? I was directed there by a quick podcast from Amal Mattu), which provides a great approach to the common presentation of syncope.


Until now, I was following the wisdom of Dr Kylie Brown, who imparted this strategic mnemonic to remember the San Francisco syncope rule:

Congestive cardiac failure
Haematocrit low
ECG changes (long QTc, heart block, WPW, Brugada, LVH)
Systolic BP low
Short of breath

This, and many other, risk stratification devices have been developed, with ALiEM providing a good summary of these. Life in the Fast Lane, as always, has a great summary of syncope, with the helpful HEAD HEART VESSELS mnemonic of causes (originally from Syncope, Vertigo and Dizziness chapter by William F Young Jr in Emergency Medicine Secrets; see comments below).

What this article brings to the table is a stepwise approach to risk stratification, with the vast majority of presentations requiring only an ECG and able to be discharged. The majority of diagnoses for causes of syncope are made in the ED, and admission may only have limited additional value.


They present an algorithm for management that steps through the risk factors and suggested disposition based on these.


The questions to consider when approaching a presentation of syncope are:

  1. Is it really syncope?
  2. Does the patient have high risk markers? The absence of any of these suggests a very low risk of a significant cardiac cause for their syncope.
  3. Is the history suggestive of vasovagal or orthostatic syncope?


If the patientĀ did not have true syncope, does not have any high risk markers, or has a presentation consistent with vasovagal or orthostatic syncope, they have a very low risk for cardiac cause for their syncope, and admission can be avoided.


A good history provides more useful and more accurate information in most patients.


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