Written by Clay Smith
Clinical exam and ECG are helpful in sorting out whether a patient does or does not have cardiac syncope.
Why does this matter?
Does clinical assessment have any value in patients with syncope? Turns out, there are some aspects of the history and ECG that can help us tease out whether or not a patient has experienced cardiac syncope or not.
DFO deep dive
Here are the clinical variables that make cardiac syncope more or less likely.
PLR = positive likelihood ratio; NLR = negative likelihood ratio. Generally a PLR ≥10 and NLR ≤0.1 are considered more powerful +/- diagnostic discriminators. A figure (below) integrates the ESC, AHA, and main findings of this review into one place.
More or less likely: Age ≥35, PLR 3.3; age <35, NLR 0.13.
More likely: Atrial fibrillation/flutter history, PLR 7.3; severe structural heart disease history, PLR 3.3-4.8; cyanosis during syncope, PLR 6.2; symptoms of chest pain/dyspnea prior to syncope, PLR 3.4-3.8.
Less likely: Prior to syncope - symptoms of “mood change or prodromal preoccupation with details,” NLR 0.09; feeling cold, NLR, 0.16; headache, NLR, 0.17; mood changes after syncope NLR 0.21; “inability to remember behavior prior to syncope,” NLR 0.25; EGSYS score < 3, NLR 0.12-0.17.
This is not in the review, but we just covered an article on the benefit of the Canadian Syncope Risk Score plus monitoring in the ED that also looks very promising.
Did This Patient Have Cardiac Syncope?: The Rational Clinical Examination Systematic Review. JAMA. 2019 Jun 25;321(24):2448-2457. doi: 10.1001/jama.2019.8001.
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