Clinical Policy: Critical Issues in the Evaluation and Management of Patients
Presenting With Syncope
February 3, 2001

I. What data help to risk-stratify patients with syncope?
Patient management recommendations: historical data.

Level B recommendations.
  1. Patients older than 60 years with a history of cardiovascular disease
should be considered to be at high risk of adverse outcome.
  2. Patients younger than 45 years without cardiovascular disease or other
risk factors should be considered at low risk of adverse outcome.

Level C recommendations.
Patients with suspected reflex mediated or vasovagal syncope should be
considered at low risk of adverse outcome.

Patient management recommendations: physical examination data.

Level B recommendations.
Patients with physical examination findings of congestive heart failure should
be considered at higher risk of adverse outcome.

Level C recommendations.
Patients with physical examination findings consistent with cardiac outflow
obstruction should be considered at higher risk of adverse outcome.

Patient management recommendations: diagnostic testing data.

Level B recommendations.
Obtain a standard 12-lead ECG in patients with syncope when history and
physical examination do not reveal a diagnosis.

Level C recommendations.
In patients without a clear etiology of syncope after history and physical
examination: Initiate cardiac monitoring.

Patient management recommendations: admission after a syncopal event.

Level B recommendations.
Admit patients with syncope and any of the following:
1. A history of congestive heart failure or ventricular arrhythmias
2. Associated chest pain or other symptoms compatible with acute coronary
syndrome
3. Evidence of significant congestive heart failure or valvular heart disease
on physical examination
4. ECG findings of ischemia, arrhythmia, prolonged QT interval, or bundle
branch block

Level C recommendations.
Consider admission for patients with syncope and any of the following:
1. Age older than 60 years
2. History of coronary artery disease or congenital heart disease
3. Family history of unexpected sudden death
4. Exertional syncope in younger patients without an obvious benign etiology
for the syncope