SYN
 COPE    2018 ESC Guidelines for the diagnosis and management of syncope
ambulatory bp monitoring
autonomic function test
cardiac markers
carotid sinus massage Carotid Sinus Massage
coronary angiogram
ep study EP Study
holter monitoring
exercise stress test
loop recorder Loop Recorder
tilt testing Tilt Testing
video recording
.1 definition 
.2 initial eval 
.3 tests 
.4 rx 

HeartRhythmBox
CONCEPT
to document • to provoke
  • ABPM (ambulatory BP monitoring)
    to detect nocturnal hypertension.
    to detect and monitor OH in daily life.
  • Holter Monitor
    considered in frequent syncope or presyncope (≥1/wk).
  • Loop Recorder
    External recorder: for those with once-in-4wks episode.
    ILR (implantable loop recorder) : indicated in recurrent syncope or syncope with high-risk criteria after unrevealing evaluation.
  • Video Recording
    considered home video recordings of spontaneous events.
  • Autonomic Function Test
    consider Valsalva maneuver or Deep-breathing test if neurogenic OH is suspected.
  • Carotid Sinus Massage
    indicated in patients>40 years of age with syncope of unknown origin compatible with a reflex mechanism.
  • EP Study
    old MI + unexplained syncope + not yet indicated for ICD.
    bifascicular block + unexplained syncope
  • Exercise Testing
    syncope during or shortly after exertion.
  • Tilt Testing
    suspected; but not confirmed by initial evaluation, of reflex syncope.
    assessment of delayed OH, POTS vs psychogenic syncope.
Carotid Sinus Massage
BP / ECG Monitor
Max Pulse
Use 3 fingers
Massage Up/Dn

R | L
Supine & Upright
10s each
0.24%
Stroke Risk
I CSM is indicated in patients >40 years of age with syncope of unknown origin compatible with a reflex mechanism.
I Carotid Sinus Syncope (CSS) = CSM with bradycardia and/or hypotension + reproducible symptoms
OK No contraindications.
Careful in those with prior stroke/TIA, or known carotid stenosis.
Electrophysiologic Study
brady
bifascicular block (bfb)
rationale on bfb
sinus node dysfunction snd
EP Study for Suspected Bradycardia
Bifascicular Block | Sinus Node Dysfunction
  IIa   EPS should be considered in a patient with bifascicular block with unexplained syncope.
  I   +EPS = HV ≥70ms or high-grade AV block during incremental A pacing = pacemaker
Kalscheur et al. PACE 2016; 39:1126–1131
  • Retrospective data (n=43)
  • 0 recurrent syncope in EPS-guided therapy group.
  • 29% recurrent syncope in empiric pacemaker group.
  • 27% in empiric group progressed to high degree AV block
  • Empiric pacemaker in BFB + unexplained syncope remains a IIa recommendation in 2017 ACC guidelines
  IIb   In asymptomatic sinus bradycardia, EPS may be considered in a few instances when non-invasive tests have failed to show a correlation between syncope and bradycardia.
tachy
post MI
others
EP Study for suspected tachycardia
50M, old inferior wall MI, LVEF 50%, with syncope. EP study induced monomorphic VT.
 I  EPS is indicated unexplained syncope + previous MI or other scar related conditions.
EP Study for syncope with various cardiac conditions
ref: 2017 ACC guidelines for SCA
 IIa  Ischemic CM, non-ischemic CM, or congenital heart disease who do not meet ICD indications for primary prevention.
 IIb  Limited value in Brugada syndrome or ARVC.
 III  No benefit in long QT syndrome, short QT syndrome, CPVT, HCM, or early repolarization syndrome.
60°-70°


Tilt Testing

Tilt testing should now be considered a means of exposing a hypotensive tendency rather than being diagnostic of vasovagal syncope.
  IIa   Considered in patients with SUSPECTED reflex syncope, orthostatic hypotension, postural orthostatic tachycardia syndrome, or psychogenic pseudosyncope.
Advice A negative tilt table test DOES NOT EXCLUDE a diagnosis of reflex syncope.
Tilt test should not be used to assess treatment efficacy.
ECG Monitoring
Holter Monitoring
Yield: 1-2%
Recording Length: 24-48hr
External Loop Recorder
Yield: 24.5%
Recording Length: 2-4wks

Ref: Locati et al. Europace. 2016 Aug; 18(8): 1265–1272.
Implantable Loop Recorder (ILR)
Yield: 35%
Recording Length: 1-3yrs

Ref: Indications for the use of diagnostic implantable and external ECG loop recorders
 I  ILR: High risk and unexplained syncope after comprehensive evaluation.
 I  ILR: Early evaluation in recurrent syncope.
Advice Pre-test selection influences the yield.
Event recorder or smartphone applications have limited value in evaluation of syncope.