Syncope/Collapse

Patient Presentation: Patients who have had episodes of transient loss of consciousness (TLoC) and do not have a firm diagnosis of uncomplicated faint, situational syncope, orthostatic hypotension, or epileptic seizures.

Initial Assessment:

• Detailed history of TLoC including any previous events.
• Medical history and any family history of cardiac disease or inherited cardiac conditions.
• Drug therapy at the time of TLoC and any subsequent changes.
• Clinical examination, including full cardiovascular examination and measurement of lying and standing blood pressure.
• 12-lead ECG and examination of previous ECG recordings if available.

Ambulatory ECG:

• Choose based on the person's history and frequency of TLoC:
  • TLoC several times a week: Holter monitoring (up to 48 hours if necessary).
  • TLoC every 1 to 2 weeks: External event recorder.
  • Infrequent TLoC (less than once every 2 weeks): Implantable event recorder.

General Information for Patients:

• Discuss possible causes of their TLoC.
• Explain benefits and risks of tests offered.
• Review results of tests performed.
• Discuss reasons for further investigations.
• Explain the nature and extent of uncertainty in the diagnosis.

Fitness to Drive:

• Advise patients who have experienced TLoC and are referred for cardiac assessment not to drive until their assessment is concluded.
• Refer to DVLA guidelines for assessing fitness to drive.

• Suspected Structural Heart Disease: Refer to cardiology for further investigation.
• Suspected Cardiac Arrhythmia: Arrange for appropriate cardiology referral.
• Unexplained Syncope: If syncope is exercise-induced, arrange for exercise testing unless contraindicated.
• Recurrent TLoC with Unclear Diagnosis: Consider referral for neurological assessment if psychogenic non-epileptic seizures or psychogenic pseudosyncope are suspected.

• Firm Diagnosis in Primary Care: If the diagnosis is clear and management can be undertaken in primary care, such as uncomplicated faint or situational syncope.
• Single Episode of TLoC with Clear Cause: No referral necessary if the episode is isolated and the cause is identified and managed.