i'm pleased to be here today on behalf of acc to talk about syncope i've been asked to cover some tips and tricks around the things that are most important to do in evaluating syncope and some things that or perhaps we as a community should not be doing and this stems from my involvement and request for the guidelines that came out in 2018 that are really the founding direction for practitioners for managing syncope so we'll start with quick conflicts of interest i don't have any commercial relationships this is because i have in principle organizational or time conflict of interest which is uh displayed here so i have leadership roles both in the canadian cardiovascular society and the heart rhythm society and i don't see that having any direct impact on today's presentation so we'll talk about the do's and don'ts i've seen to be evaluation and i want to start with something that may seem too obvious to you and that is take the time and invest in a history so if you look at the diagnostic cascade the highest yield test that you can do in syncope is not an ecg or a monitor it's actually a thoughtful history as well as a cursory physical examination and and the reason for that is that in fact structured histories can be very diagnostic and there's something called the calgary syncope score i'll show an example in a moment that is a structured history we simply ask seven questions and that helps to differentiate between neurologic and cardiovascular causes and there are three versions of this that's been led by bob sheldon and this is the foundation of this one of the things that's often overlooked is the idea of seeking out an observer there's an observer who notices for instance pallor or seizure-like activity those elements of things are postural aspects for the the occurrence of injury are key clues to try to determine the probable cause and then based on that that's really what directs the extent and nature of investigations so you know if you look at that the next thing that helps is the confirming tests so for example you have a young patient who has a story compatible with vasovagal syncope you do an ecg to ensure that there are no suspicions or concerning findings and that's all that you need to do or because you hear something else or you see something else that makes you suspect something and then we get into those kinds of tests that i just called expensive or invasive tests and these are tests that involve hospitalization they involve provocation they involve imaging etc those elements of things but again the yield of those is relatively low and recognize between yourself and the patient that a substantial number of people will remain undiagnosed so again invest in the history it's the most valuable tool that you have and so uh this is a good example of the guidelines um co-director dr robert sheldon who went through the process of saying what are all the questions that we ask patients who have syncope how do we manage those questions which are most important and actually went through a structured process to identify those that were most relevant to arriving at a diagnosis based on a large cohort of diagnosed syncope patients and so you see here here's the seven questions and if you have a positive score or a negative score that directs you towards the question of either seizures versus syncope for many people who are experienced and see lots of syncope patients this may seem too simple but this is also a very powerful tool to teach people such as your emergency department such as your primary care referring cardiologists about the value of things and so a good example would be diaphoresis points to vasovagal syncope head turning points to to seizure and so on so these are key simple things to teach that are quick easy and evidence-based so the next thing is more around the question of what to do or what not to do so this is in the don'ts which is in general when you look at the evaluation of syncope we invest less time in the history and much more time in diagnostic testing and in fact the yield of many forms of diagnostic testing that's done frequently is very low so for example doing a neurologic workup in particular things like carotid dopplers and imaging has a very low yield and even eeg which is the meaningful differential diagnosis in patients with transient loss of consciousness has a low yield limit cardiac imaging unless there's clinical suspicion so an older patient who presents is a different question than a young healthy person giving the story compatible with vasovagal syncope an ischemic workup and biomarkers can detect evidence of disease but it's unlikely to be related to syncope and they're very low yield so in general they're to be dispersed unless there's clinical suspicion that stems from the history and tilt testing and ep studies are done but quite rarely so they're really done by electrophysiologists when there's really no recourse for an answer and ctp is recurrent not because they're standard part of upfront evaluation of centerpiece and the last thing is which we'll talk about in a moment in some detail is admission to hospital is done quite frequently in some environments there's good precedent and evidence base the admission rates from your emergency room can be as low as 10 to 20 percent and in many hospitals submission rates are 50 to 80 percent and so most patients do not need to be admitted if you have access to either interim observation units or uh rapid outpatient assessment for diagnostic evaluation so one of the do's one of the key do's is i can say from firsthand experience the group led by dr shen and sheldon went through an immense exercise of compiling evaluating the data and creating helpful decision tools and flow diagrams and recommendations for the management of the sinkib that are in the 2018 guidelines so take advantage of them there's a very nice executive summary for something uh concise that has really focuses on things like these types of diagnostic algorithms you can look at the strength of recommendations around in general you should do this or you would usually do this like a class 1 and 2a as you see in figure 2 here or in general it's possible to do this but it's not a usual recommendation like a tier b as you see on the far right side so take advantage of that and again that very nice executive summary is easy to digest one of the do things to do is on initial evaluation which is often in the emergency room or with hospitalization is to think about risk and this is a little tricky it's not quite straightforward so from a risk perspective i think the key things to think about is if you look at those things that predict risk these are emergency room developed parameters that are largely focused on prognosis not on diagnosis so for example if you look at the short-term and long-term risk factors most of them reflect basically comorbidities that are cardiovascular in nature so on the one hand these predict that if you have syncope and you have heart failure your prognosis isn't good the flip side is that the heart failure may not be the cause of syncope so much as the combination of ambient hypotension and hypotensive drugs so i think in this situation the thing to remember is if you're gauging pro the prognostic implications for syncope and look at the comorbidity list on the other hand if you're looking for a diagnosis you're going to need something more specific to the details that are within the history to try to establish concerns regarding whether this is hypotension whether this is arrhythmia whether this is related the life-threatening arrhythmias like ventricular arrhythmias where for instance hospitalization monitoring strategies and electrophysiology consults are the mechanism by which to try to get to the bottom of that the other thing i haven't gone into is this question about other coborbid conditions or cardiovascular conditions that are more occult we will talk about that in a moment these are other things where careful history can be very helpful to raise suspicion about some of these less evident but potentially concerning causes of syncope so one of the reasons i want to bring this up is because i'd like to focus somewhat on the young to say there are some details of the young that are often overlooked so one of my roles in life is i run a cardiogenetics clinic that's focused on inherited arrhythmias and in that situation we see individuals who have had syncope and these are often younger middle-aged individuals where syncopies come up and someone has suspected something more concerning based on diagnostic testing or family history and so investing a little bit of time in the young is very important and so the first thing is the majority of the time particularly early in the phase of evaluation of syncope most patients are going to have vasovagal synthetic a thoughtful history typically a single ecg to ensure that's normal is all that's necessary for most patients with syncope and in fact in primary care the majority of patients with vasovagals and could be never get to a specialist the second thing is there are some details in the history against a few simple questions can be very helpful to try to exclude or reduce the chance that you're missing something an example would be long qt syndrome or rugata or a latent cardiomyopathy such as arvc so things like syncope during exertion sin could be without a prodrill same could be in the supine or recombinant position anyone with a family history of sudden death before the age of 50 or when some the context is unusual when they walk you through the process of what happened they will tell you that an alarm clock went off that they were swimming but it was not in difficult waters and they had an episode these are key clues to look for those blatant but important things particularly in the young so in conclusion then the foundation for saint can be evaluation is a thoughtful history and if you are interested structured questions can be very helpful both for yourself but also to teach to the care team around you the second thing is to trust your judgment and limit diagnostic testing so the history should drive the extent of diagnostic testing and that leads to the question about risk stratifying either through diagnostic testing for example an echo to exclude or undocument the evidence of structural heart disease or to inform the decisions about next steps in terms of both diagnostic testing but also admission to hospital most patients do not need admission to hospital one of things the guidelines advocates for is that there is a good opportunity for interim monitoring through an observation unit in the emergency department for 12 to 24 hours that precludes the need for admission some urgent testing can get done to exclude high risk and these patients can then be managed in an ambulatory setting and the last is to be thorough in the clinical assessment particularly founded on the history to look for risk clues especially in the young so make a thoughtful history will allow you to diagnose ways of vagal syncope and discharge the patient or to be concerned about more high-risk situations and then pursue a more extensive evaluation so i hope this has been helpful to you i try to be an open access person and happy to answer any questions if they arise you can email me and i'll do my best to respond in a timely way and lastly i'm grateful to acc for an opportunity to be here and hopefully we have all learned something today