IM faculty here, I'm sharing some tips for you, your students, or residents. This week let’s talk about Syncope (Topic 7 of 8).
Passed out + woke up quickly = think true syncope → transient complete loss of consciousness from global cerebral hypoperfusion with rapid, full recovery.
The 4 buckets you need to know:
Reflex (vasovagal) – most common
Younger patients. Triggered by pain, fear, heat, coughing, urination, etc.
Prodrome = nausea + diaphoresis → often fatigue afterward.
Cardiac – highest mortality
Arrhythmias most common, but also structural disease, PE, etc.
Red flags: no prodrome, sudden drop, exertional or supine syncope, chest pain, palpitations.
Orthostatic
Older adults. Happens after standing. Think dehydration, meds, alcohol, autonomic dysfunction (e.g., Parkinson disease, Diabetes Mellitus).
Psychogenic (pseudosyncope)
Often younger patients with anxiety/depression.
Think seizure instead if aura, abnormal posturing, tongue biting, head turning, prolonged confusion.
Board pearls:
Every patient gets an ECG.
Exertional or supine syncope = cardiac until proven otherwise.
No brain CT/MRI unless focal neurologic deficits.
Carotid ultrasound has no role.
Tilt-table testing = only if suspected recurrent vasovagal/orthostatic after unrevealing initial workup.
PE can present as syncope, don’t miss it.
Admit / urgent cardiac eval if:
Exertional or supine syncope
Chest pain or palpitations
Known heart disease
Family history of sudden death
Hypotension/bradycardia
Abnormal ECG
One-liner:
Nausea + sweating before = vasovagal. Sudden collapse with no warning = cardiac until proven otherwise.
If you want to read more similar clinical tips for your practice and exam, Subscribe to my Substack here. I post regularly over there but will continue to post here periodically!
American College of Cardiology / American Heart Association 2017 syncope guidelines.