Syncope in the older patient:
ECGs you must know
Dr Steve W Parry
Clinical Senior Lecturer and Honorary Consultant Physician
Falls and Syncope Service, Royal Victoria Infirmary and
Institute for Ageing and Health, Newcastle University
Fig 1 Causes of syncope by age
Parry SW, Tan MP BMJ 2010;340:c880
Copyright ©2010 BMJ Publishing Group Ltd.
Streamlining and Risk Stratification:
Initial Evaluation
 True syncope from “non-syncopal” disorders
 Cardiac from non-cardiac syncope
 Clinical features and basic investigations
suggesting a diagnosis or route of referral
Basic Evaluation
• History
– Witness account
– Clues to underlying diagnosis
• Stokes-Adams presentation
• VVS, CSS, OH
• Familial sudden death syndromes
• Seizures, psychiatric disorders
• Subclavian steal, CVD
• Examination
– Cardiovascular, neurological
• 12 lead ECG
– Normal: low risk of cardiac syncope
– Abnormal: independent predictor of increased mortality
• Lying/standing blood pressure measurement
Syncope: Certain diagnosis based on
symptoms, signs and ECG findings
•Classical vasovagal syncope
•Precipitating events (fear, pain, emotional distress,
instrumentation, prolonged standing) associated with typical
prodromal/post event symptoms
•Situational syncope
•Micturition, defaecation, cough, swallowing
•Orthostatic hypotension
•Syncope or pre-syncope documented during orthostatic fall in
blood pressure
Certain diagnosis based on symptoms,
signs and ECG findings
•Cardiac ischaemia related syncope
•Arrhythmia-related syncope
•Clear ECG evidence of symptom-rhythm correlation
•(Mobitz II, 3rd degree AVB, SVT/VT, sinus pauses >3
sec etc)
•Suggestive from history or ECG
Brugada syndrome
Arrhythmogenic right ventricular dysplasia
T inversion in right precordial leads
Epsilon waves
Ventricular late potentials
Ventricular tachycardia
Ventricular fibrillation
Normal ECG
Long QTc
QTc= QT/√R-R
Torsade de Pointes VT
Mobitz I AVB (Wenckebach)
Mobitz II AV block
Complete heart block
Complete heart block
Bifascicular block: RBBB with LAFB
(LAD broadened QRS)
Trifascicular block:
RBBB with 1st degree AVB and LAD
Sinus node dysfunction with junctional
bradycardia
Early repolarisation as normal variant
Wolff Parkinson White Syndrome
PR depression in pericarditis
ECG abnormalities suggesting
arrhythmic syncope
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RBBB, LBBB
Very prolonged PR interval
Previous MI
Chronotropic incompetence
– cf trend on 24 hour ECG
When is syncope scary?
Red flags in transient loss of
consciousness
• Prolonged unconsciousness, post-event confusion
and/or neurological signs, lateral tongue biting
• Unheralded syncope with prompt recovery (Stokes
Adams attack) or other features suggesting lifethreatening arrhythmias
• Family history of premature sudden cardiac or
unexplained death
• Syncope during exercise
• Supine syncope
Red flags in transient loss of
consciousness
• Chest pain, breathlessness
• Palpitations preceding syncope
• Syncope in patients with heart failure or established
heart disease
• Frequent and/or injurious syncope
• Syncope while driving
• ECG abnormalties
– Long QTc, SCD, sinus brady <50, broad QRS
• Anaemia
• Electrolyte imbalance
Risk prediction tools
• Attempts to quantify risk and identify those at
most risk following presentation
• Predominantly A&E based and developed
• OESIL, EGSYS, Boston Syncope Rule, ROSE rule
• San Francisco Syncope Rule (Quinn et al Ann Emerg Med
2004)
– Recent meta-analyses and systematic reviews (Serrano et
al Ann Emerg Med 2010) suggest SFSR is most promising
– Problems in older patients
• None have gained wide acceptance
• Comparison with clinician best judgement shows
equivalent risk prediction (Quinn et al Am J Emerg Med
2005)
San Francisco Syncope Rule
(Quinn et al Ann Emerg Med 2004, 2006)
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History of congestive heart failure
Haematocrit <30%
Abnormal ECG or cardiac monitoring
Systolic BP <90mmHg at triage
ROSE (Risk Stratification of Syncope in the
ED) (Reed et al EMJ 2007)
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BNP >300pg/ml
Bradycardia <50 bpm
PR exam with faecal occult blood (if GIB suspected)
Anaemia
Chest pain
ECG with q wave
Sats <94% on room air