1. Patients with suspected syncope should be investigated by cardiologists Dr NR Stout

3. Syncope a transient, self-limited LOC onset rapid recovery spontaneous, complete, and usually prompt transient global cerebral hypoperfusion

4. Classification of syncopal disorders Real or apparent LOC Syncope  Reflex mediated  OH  Cardiac  Cerebrovascular Non-syncopal With LOC (e.g. seizures) Without LOC (e.g. NEAD)

5. Soteraides et al NEJM 347:878-885

8. Copyright ©2010 BMJ Publishing Group Ltd. Parry, S. W et al. BMJ 2010;340:c880 Causes of syncope by age

9. What happens to patients with syncope? About 50% do not seek medical attention GP, A&E Secondary care –Cardiologists –Geriatricians –Physicians –Neurologists

10. Misdiagnosis of Epilepsy 74 patients with epilepsy Mean age 40 years Continued attacks despite adequate drug treatment (n= 36) Uncertainty about the diagnosis (n=38). HUT & CSM – ECG,BP & EEG monitor 10 patients ILR Alternative diagnosis was found in 31 patients (41.9%) 19 positive HUT 10 other cardiac causes 2 psychogenic seizures Zaidi et al J Am Coll Cardiol 2000;36:181– 4

13. www.escardio.org/ guidelines

14. Heart 2008;94;1620-1626

15. Sensitivity 95% Specificity 61% Heart 2008;94;1620-1626

16. NICE Draft Guidelines Serious condition? Urgent cardiology Yes No Identifiable cause? Treat VVS/OH Yes Epilepsy features? NeurologyCardiology No Yes No

17. Treat VVS/ OH Yes Neurology No Yes ECG abnormality Heart failure TLoC on exertion FH of SCD <40 years Age>65 years and no prodromal symptoms New or unexplained SOB Heart murmur

18. No Treat VVS/ OH Yes Heart block. Persistent bradycardia. Ventricular arrhythmia (QT syndromes). Brugada. WPW. L/R ventricular hypertrophy. Abnormal T wave inversion. Pathological Q waves. Atrial arrhythmia. Paced rhythm.

19. NICE Draft Guidelines Serious condition? Admit Yes Identifiable cause? No Treat VVS/OH Yes Epilepsy features? Neurology Cardiology No Yes No

20. Unexplained syncope A proportion will have cardiac cause NICE recommend heart rhythm monitoring depending on frequency of symptoms 24 hr ECG, external loop recorder or ILR Preceeded by CSM if over 60 years old

21. ILR in unexplained syncope DGH setting in UK 201 patients with unexplained syncope Mean age 74 randomised after a basic clinical workup to ILR or conventional investigation. F/u over at least 6 months outcome time to ECG diagnosis ECG diagnosis in 33% ILR vs 4% conventional (HR 8.93,p<0:0001). ILR group –Quicker ECG diagnosis –Fewer investigations –Fewer hospital days –Reduced costs

22. Cardiologists should investigate syncope because: Cardiac syncope forms a significant proportion of syncope presentations Associated with increased mortality Validated pathways for syncope management aimed at identifying cardiac causes for syncope Misdiagnosis is common Cardiology have the expertise and resources to identify syncope due to cardiac disease and investigate unexplained syncope

23. “Receiving treatment they don’t need which fails to control a condition they don’t have”