Step 1: A thorough history and physical examination.
We have seen why this is important – the history and physical examination give vital clues in diagnosing nearly all causes of syncope.A careful history consists of asking details about each and every syncopal episode the patient has had, including a detailed history of when it occurred, what the patient was doing, whether there was any warning, how long it lasted, whether consciousness was regained as soon as the patient fell down, and whether the patient has found a way to abort the episodes. The physical examination should include thorough neurological and cardiac exams, and taking the blood pressure in each arm and while the patient is lying (or sitting) and standing.
By the end of the history and physical, your doctor, at the least, ought to have an excellent idea as to what is causing your syncope. When she is finished with this preliminary assessment, your doctor should be ordering no more than one or two directed tests to confirm her suspicions. She should be able to tell you what she thinks is the problem, and should even be giving you some idea of what the treatment will entail.
If your doctor has finished up with you and is standing there, shaking her head, ordering a shotgun-load full of tests and procedures, you’re both in for a very hard time.
Step 2: Directed tests or studies
After the history and physical:- If your doctor suspects a neurological cause, then she will probably order a brain scan or EEG, or in some cases, angiography (a dye study to visualize the arteries to the brain) to confirm the diagnosis.
- If your doctor has diagnosed or strongly suspects vasodepressor syncope, therapy should be initiated. In some cases, a tilt table study may be useful in confirming the diagnosis.
- If your doctor suspects a cardiac cause, or if she has no good idea as to what is causing your syncope, a non-invasive cardiac workup should be done immediately. In most cases, this work-up will consist of an echocardiogram, and in some cases a stress test.
Step 3: If the cause of syncope remains unknown after Step 2
- If underlying heart disease was discovered in Step 2, you should be referred for a full cardiac evaluation. In general, this evaluation would consist of not only a standard heart catheterization (in which the coronary arteries are visualized), but also an electrophysiology study (a catheterization evaluating the propensity of the heart to develop life-threatening arrhythmias).
- If no underlying heart disease is apparent after Step 2, your doctor might consider ambulatory monitoring (where you wear a cardiac monitor at home for some length of time), tilt table testing, and possibly stress testing if not performed during Step 2. If syncope remains undiagnosed after these studies, an electrophysiology test should be considered.
