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Syncope (Adults)

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope (April 2007)

Complete Clinical Policy on Syncope  (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments (EDs).

Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with syncope.

Exclusion Criteria. This guideline is not intended for children or for patients in whom the episode of syncope is thought to be secondary to another disease process. Among the clinical conditions specifically excluded are patients with seizures, chest pain, headache, abdominal pain, dyspnea, hemorrhage, hypotension, or a new neurologic deficit.

Critical Questions

1. What history and physical examination data help to risk-stratify patients with syncope?

  • Level A recommendations. Use history or physical examination findings consistent with heart failure to help identify patients at higher risk of an adverse outcome.


  • Level B recommendations. (1) Consider older age, structural heart disease, or a history of coronary artery disease as risk factors for adverse outcome.
    (2) Consider younger patients with syncope that is nonexertional, without history or signs of cardiovascular disease, a family history of sudden death, and without comorbidities to be at low risk of adverse events.


  • Level C recommendations. None specified.

2. What diagnostic testing data help to risk-stratify patients with syncope?

  • Level A recommendations. Obtain a standard 12-lead ECG in patients with syncope.


  • Level B recommendations. None specified.


  • Level C recommendations. Laboratory testing and advanced investigative testing such as echocardiography or cranial computed tomography (CT) scanning need not be routinely performed unless guided by specific findings in the history or physical examination.

3. Who should be admitted after an episode of syncope of unclear cause?

  • Level A recommendations. None specified.


  • Level B recommendations. (1) Admit patients with syncope and evidence of heart failure or structural heart disease.
    (2) Admit patients with syncope and other factors that lead to stratification as high-risk for adverse outcome (Figure 1).

  • Figure 1. Factors that lead to stratification as high-risk for adverse outcome.

    Older age and associated comorbidities*
    Abnormal ECG†
    Hct <30 (if obtained)
    History or presence of heart failure, coronary artery disease, or structural heart disease

    *Different studies use different ages as threshold for decisionmaking. Age is likely a continuous variable that reflects the cardiovascular health of the individual rather than an arbitrary value.

    †ECG abnormalities, including acute ischemia, dysrhythmias, or significant conduction abnormalities.




  • Level C recommendations. None specified.

Purpose of ACEP's Clinical Policies

Clinical Findings and Strength of Recommendations