The Appropriateness of an Ischemia Evaluation for Syncope

Syncope, a transient loss of consciousness, is a common symptom that occurs in ≈20% to 40% of adults at least once in their lifetime. Although this presentation is often associated with a benign course or perhaps minor injury, major morbidity may also occur.1–3 An abundance of literature has examined the various causes of syncope, but up to 40% of patients may have no identifiable etiology for syncope.1–3 Vasovagal (vasodepressor) syncope and orthostatic hypotension are usually reported as the common causes, with ischemic heart disease accounting for a very low percentage of these presentations.1–3Article see p 384Starting with the pioneering work by Kapoor et al,4 it was recognized that the presence of heart disease portends a worse prognosis for patients with syncope compared with those with no structural heart disease. Therefore, a young adult with syncope of unknown origin and no structural or electric heart disease has a better outlook than a similar patient with newly diagnosed cardiomyopathy. Multiple algorithms for syncope evaluation make this important differentiation in terms of presence or absence of structural heart disease.1–3,5,6 Thus, a search for the potential cause of syncope goes beyond mere diagnosis and should also provide risk assessment and the planning of appropriate therapy.The evaluation of syncope begins with a detailed history and physical examination, including blood pressures in supine and upright position.2,3,5,6 An ECG is reasonable for almost all patients with syncope of unexplained origin. This initial assessment can identify or be suggestive of the cause of …