Diagnostic Assessment of Recurrent Syncope

The definitive diagnosis of a cardiac arrhythmia as the basis for syncope is made by electrocardiographic monitoring during a syncopal episode. In the absence of this evidence, abnormalities demonstrated by an electrophysiologic study may suggest the etiology of syncope. Cardiac electrophysiologic testing in patients with recurrent syncope should probably be limited to patients with underlying cardiac disease. These patients are at a higher risk for sudden death and have a high incidence of electrophysiologic abnormalities. In particular, ventricular tachycardia may be evoked and specific therapy for this abnormality is associated with remission of syncope. In contrast, electrophysiologic studies in patients with no underlying cardiac disease have a very low yield of abnormal findings in the order of 10-20%, and should be performed only when there are reasons to suspect the presence of arrhythmias. Furthermore, in patients with no underlying cardiovascular disease there is a high spontaneous remission rate of syncope and the late incidence of sudden death is low, and related to the presence of other systemic illnesses. At present, the significance of nonsustained ventricular tachycardia or ventricular fibrillation induced during cardiac electrophysiologic studies in patients with no documented arrhythmias is unknown, and further prospective studies are necessary to define appropriate therapy for these patients. Further investigation is also required to clarify the spontaneous remission rate of syncope, as this information is of vital importance in assessing the success of any therapeutic modality.