Chapter 99. Syncope

A 74-year-old female with early Parkinson disease presented to the Emergency Department with loss of consciousness while standing in the sun. She thought that she did not drink enough water during the day. She initially felt bilateral shoulder pain followed by dizziness, and then recalled awakening on her porch. She injured her forearm, but recovered fully within one minute. A witness described some brief jerking movements in her arms (lasted a few seconds). Blood pressure lying and standing were 130/80 mm Hg and 90/48 mm Hg respectively. Pulse was 86 beats per minute (bpm) lying and 88 bpm standing. Other vital signs, cardiac, and neurologic examination were all normal. An electrocardiogram (ECG) showed normal sinus rhythm with a heart rate of 88 bpm.

What is the approach to the patient? What further testing is indicated? What is the diagnosis? What is her overall prognosis following this syncopal event?

A 62-year-old male passed out while voiding just after awakening from sleep. He denied symptoms beforehand and awakened promptly. On further history, he did not report prior cardiovascular symptoms. His past medical history includes long-standing hypertension and he has a 40-pack-per-year tobacco history. Cardiovascular and neurologic examination was normal. Breath sounds were distant. His ECG is shown in Figure 99-1.

What is the best approach to this patient? What further testing is indicated? What is the diagnosis? What is his prognosis if left untreated?