A 72-year-old man comes to the emergency department after a brief episode of loss of consciousness. The patient was waiting in line to purchase a movie ticket when he felt warmth and nausea and started sweating. He then collapsed to the ground and was unconscious for 1 to 2 minutes. According to his wife, who witnessed the episode, he had 2 or 3 jerking movements of his arms. He had no tongue biting or urinary incontinence.
The patient was briefly hospitalized after a similar episode 1 year ago and work-up including blood tests, ECG, and telemetry were normal. His medical problems include hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and diverticulosis.
Blood pressure is 130/84 mm Hg and pulse is 72/min with no orthostatic changes. The patient is alert and interactive. There are no cardiac murmurs or focal neurologic findings.
ECG shows sinus rhythm with normal intervals. Blood cell counts, serum chemistry studies, and initial cardiac troponin I level are within normal limits.
Which of the following is the best next step in management of this patient?

Question

A 72-year-old man comes to the emergency department after a brief episode of loss of consciousness.  The patient was waiting in line to purchase a movie ticket when he felt warmth and nausea and started sweating.  He then collapsed to the ground and was unconscious for 1 to 2 minutes.  According to his wife, who witnessed the episode, he had 2 or 3 jerking movements of his arms.  He had no tongue biting or urinary incontinence.
The patient was briefly hospitalized after a similar episode 1 year ago and work-up including blood tests, ECG, and telemetry were normal.  His medical problems include hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and diverticulosis.
Blood pressure is 130/84 mm Hg and pulse is 72/min with no orthostatic changes.  The patient is alert and interactive.  There are no cardiac murmurs or focal neurologic findings.
ECG shows sinus rhythm with normal intervals.  Blood cell counts, serum chemistry studies, and initial cardiac troponin I level are within normal limits.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Syncope can be benign or a sign of serious underlying pathology; history, physical examination (including orthostatic vital signs), and ECG findings can provide a diagnosis in 60% of cases. For patients in whom the etiology of syncope is unclear, an assessment for high-risk features is important. The presence of >1 high-risk feature raises suspicion for a serious cause of syncope (eg, cardiac arrhythmia, pulmonary embolism, severe hypovolemia) and suggests the need for further investigation and possible admission. high-risk features However, this patient has a classic trigger (eg, prolonged standing) and an autonomic prodrome (eg, diaphoresis, nausea, generalized warmth) consistent with neurocardiogenic (vasovagal) syncope. He has no concerning findings (eg, associated chest pain, abnormal vital signs, abnormal physical examination), has no signs of injury, and has had a prior workup that was unremarkable. Patients with clear neurocardiogenic syncope who have returned to baseline can be reassured and discharged with outpatient follow-up. In a study of prognosis of syncope among participants in the Framingham Heart Study, those with neurocardiogenic syncope had no increased risk of all-cause mortality, myocardial infarction, or stroke. (Choice A) Admission for telemetry monitoring is indicated in patients with high suspicion of syncope due to cardiac arrhythmia. Suspicious features include syncope while sitting or lying supine, exertional syncope, absence of prodrome, ECG abnormalities, and prior history of coronary or structural heart disease. (Choice C) Outpatient ambulatory ECG (Holter) monitoring can be appropriate to assess for cardiac arrhythmia in those whose presentation is not entirely consistent with neurocardiogenic syncope, but in whom there is relatively low suspicion of serious cardiac arrhythmia (eg, ventricular tachycardia). (Choice D) Brain imaging and electroencephalography can be helpful in diagnosing seizure disorder. Loss of consciousness due to seizure is typically accompanied by a prolonged postictal phase and may involve bowel or bladder incontinence and unusual body posturing. Patients with neurocardiogenic syncope can have brief tonic-clonic movements due to transient global cerebral hypoperfusion; these movements alone do not indicate seizure activity. (Choice E) Upright tilt-table testing is sometimes used in patients with an unclear diagnosis of neurocardiogenic syncope or to differentiate neurocardiogenic syncope from orthostatic hypotension syncope. Educational objective: For patients in whom the etiology of syncope is unclear, an assessment for high-risk features (eg, new ECG changes) is important to guide the need for further investigation. Patients with a clear presentation of neurocardiogenic syncope (classic trigger and autonomic prodrome) can be reassured and discharged with outpatient follow-up. __________ References: Clinical practice. Neurocardiogenic syncope. (http://www.ncbi.nlm.nih.gov/pubmed/15758011) Synopsis of the National Institute of Health and clinical excellence guideline for management of transient loss of consciousness. (http://www.ncbi.nlm.nih.gov/pubmed/21930835) Guidelines for the diagnosis and management of syncope (version 2009). (http://www.ncbi.nlm.nih.gov/pubmed/19713422) San Francisco Syncope Rule to predict short-term serious outcomes: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/21948723) Incidence and prognosis of syncope. (http://www.ncbi.nlm.nih.gov/pubmed/12239256)

A 72-Year-Old Man Comes to the Emergency Department After a Brief