Cardiology  |  Cardiac Syncope Pathway - Consider Cardiac Arrhythmia

Syncope/severe presyncope due to cardiac arrhythmia is usually a sudden event without significant associated symptoms and the person is remarkable well immediately after the event. 

The following will assist with grading of referral and the information is requisite to the referral being accepted:

Symptoms

Description and frequency:

• Syncope episode(s) described
• Witness corroboration
  
  

Frequency - may facilitate direct referral for Holter monitoring:

• Multiple episodes per day
• Daily
• Several times per week
• Weekly
• Less than one weekly
• Single episode only

Important Co-morbities

Patient history of heart disease - the following are important:

• Heart failure
• Coronary arterial disease
• Known arrhythmia
• Valvular heart disease
  
  

Family history of premature sudden death - the following are important:

• Sudden cardiac death.
• Arrythmogenic  right ventricular cardiomyopathy.
• Hypertrophic obstructive cardiomyopathy.
  
  

Medication
List current medications

Other Medical History:
Detail any relevant medical history

Examination
Detail all relevant findings - include specifically BP, heart sounds, pulse, and character

Note on Aortic Stenosis

Aortic stenosis might indicate need for more urgent review:

• located at the right sternal edge.
• radiates to the carotid.
• signs of severity include narrow pulse-pressure, slow-rising pulse, aortic  thrill, fourth heart sound.
• heart failure symptoms are generally a late manifestation of aortic stenosis.

Note on Aortic Stenosis

Investigations:

• Detail relevant lab investigations - include specifically FBC, creatinine, electrolytes, TFT
• ECG - must be done
• Copy forwarded of ECG or report abnormal findings - note if patient symptomatic at time
• heart block, arrhythmia, delta waves, Q waves, QRS duration, LBBB, RBBB, hypertrophy, ST changes

Note Special Abnormalities:

Wolff-Parkinson-White Syndrome - short PR interval and delta wave:

• Short PR interval  < 120 ms - measured from start of P wave to start of QRS complex.
• Prolonged QT interval.
• Long QT interval - > 0.48 seconds in female and  > 0.46 seconds in males.
• Calculate corrected QT (QTC) which is the QT/üRR interval.
  
  

Investigations:

• Detail relevant lab investigations - include specifically FBC, creatinine, electrolytes, TFT
• ECG must be done
• Copy forwarded of ECG or report abnormal findings - heart block, arrhythmia, delta waves, MI

Social

Advise any important social implications:

• It is mandatory for a medical practitioner to advise patient of legal driving restrictions.
• Medical Aspects of Driving.
• indicate if driving essential to employment.
• indicate if at risk in present living arrangements.