3. Aims • Brief overview • Identifying Syncope • Identify patients at risk • SCD • risk of physical injury • DVLA regulations

4. What is dizzy turns, blackouts and palpitations?

5. Dizzy Turns and Blackouts Cardiac Non - Cardiac

6. Syncope “Transient Global Cerebral Hypoperfusion characterised by rapid onset, short duration and spontaneous complete recovery” (ESC)

7. 50% 15% ESC 2008 Syncope guidelines

8. Non - cardiac

9. Palpitations Cardiac • Tachyarhythmia • AF/flutter / SVT / VT • Ventricular and atrial ectopics Non Cardiac • sinus tachycardia • GORD • Anxiety / emotion • Rare (Phaechromocytoma / carcinoid)

10. How Common a Problem is it? • 1% ED referrals (40% admission rate) • Common in general population ED 0.7 GP 9 Gen population - 18-39 Syncopal episodes / visits per 1000 pt years (Ganzebaum, J Cardiovasc EP 2006 Netherlands)

12. Prognosis / Importance 1 Prognosis • Structural HD and Primary electrical disease 2 Recurrence 3 QOL 4 Cost - high (UK £611 per pt / £1080 per diagnosis)

13. Initial Evaluation • Makes diagnosis in 20 - 50% of cases • Aims - • identify syncope • Risk assess for SCD (/ risk of recurrence and injury / driving)

14. Initial evaluation, diagnosis and risk stratification • History • Examination (including lying and standing BP) • ECG (Further investigations only make diagnosis in 25% of undiagnosed patients)

15. Diagnosis of Syncope • “Transient global cerebral hypoperfusion characterised by rapid onset, short duration and spontaneous complete recovery” † Was LOC complete? † Was LOC transient with rapid onset and short duration? † Did the patient recover spontaneously, completely and without sequelae?

16. ESC 2008 Syncope guidelines

17. Examination • Evidence of structural heart disease • Murmours • Signs of heart failure • Orthostatic BP

18. ECG • Q waves (prior MI) • LBBB or RBBB and anterior or posterior hemiblock

20. ECG • Q waves (prior MI) • LBBB or RBBB and anterior or posterior hemiblock • AV block (2nd degree and higher) • Sinus bradycardia (<50 bpm) or sinus pauses >3 seconds

21. ECG 2 • Pre-excitation (short PR and delta wave) • Prolonged QT • Widened QRS • RBBB with ST elevation V1 -V3 (Brugada)

25. Important causes of cardiac syncope - “Red Flags” - Palpitations • Severe SOB • Severe Chest Pain • Syncope / near syncope

26. ARVD • Fibofatty infiltration of RV

27. Further Investigations • Echo (? structural heart disease) • Holter (useful for frequent symptoms) • Loop recorders (internal (REVEAL)/ external) • ETT (syncope during or shortly after exercise) • EP studies • Neurological / psychiatric assessment

28. DVLA Quick Guide

29. Driving Regulations DVLA Quick Guide

30. Summary • Common problem • Directed history, examination and ECG can make diagnosis in up to 50% of cases. • Initial Evaluation allows identification of high risk patients for speedy referral / investigations