Get a Diagnosis: Additional Testing

Looking for a Cardiac Cause (Heart)

Additional testing would be indicated if the person's fainting or orthostatic problems are not just a one time event. More testing would be needed if they happen more often, such as daily or weekly, or they interfere with daily life, if the symptoms are severe or if not all the person's symptoms have been explained.

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The big question - are the orthostatic symptoms due to a heart problem?

If a person already knows they have a heart problem or it is suspected, there is a good chance that the cause of the syncope (fainting) is heart-related (cardiac)^1-3. Heart rhythm or how fast the heart is beating is the most common cause of fainting due to the heart. It can be either from beating too fast or too slow. Medications can cause the problem of fast or slow heart rate.

It is possible to have a cardiac problem and a non-cardiac type of fainting (syncope) or orthostatic problem.³

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What would suggest there might be a heart problem?

There is information in a person's own history, their family's history of heart conditions and the medications taken that would suggest the fainting is due to a heart problem. Some of the information would be:

    •   Fainting during exertion , while lying down or right after the heart has suddenly starting beating fast

    •   Past history of heart condition

    •   Family history of sudden death, congenital rhythm heart condition or fainting

    •   Medications used for high BP, angina (chest pain due to heart disease), heart medications for rhythm problems

    •   EKG - Is not normal. For example it suggests part of the heart is not getting enough blood flow/oxygen (ischemia) or there is something not normal about the way it is beating

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What should be done:

• The first test is an EKG (electrocardiogram, also abbreviated as ECG).
• Discuss findings: You and your doctor should discuss the history, exam and EKG findings: what they mean and what tests might be needed. You might also discuss if (or when) you will need for a referral to a specialist (cardiologist).
• Other heart tests that might be ordered by the primary physician or by the cardiologist:
  • Echocardiography, when there is previous known heart disease or data suggestive of structural heart disease or syncope secondary to cardiovascular causes.,^2,4
  • Holter monitor (24-hour tracing or the heart beats) when there is a suspicion of arrhythmic syncope³

    Stress test/electrophysiologic studies (EPS) have a higher diagnostic yield than the Holter monitor and should be obtained for any patient with a suspected arrhythmia as a cause of syncope.⁴

  • Exercise Stress Test -

    A cardiac stress test is appropriate for patients in whom cardiac syncope is suspected and in whom have risk factors for coronary atherosclerosis. This test can assist with cardiac risk stratification and can guide future therapy.⁴

  • Ischemia evaluation [coronary artery disease (blood vessel with plaque)] - check for 'angina'
• Orthostatic challenge: [in office -lying-to-standing orthostatic test (see First Evaluation for details). If the EKG is abnormal or their is a history of heart disease, this should only be done under medical supervision. Other option: head-up tilt table testing - when fainting/syncope happens more when the person is standing or there is a suspicion of a reflex mechanism².  To learn more, go to Reflex Syncope/Fainting.
• There are many other special tests that a cardiologist would recommend after seeing the results of the first tests.

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References:

1. Strickberger SA, Benson DW, Biaggioni I, Callans DJ, Cohen MI, Ellenbogen KA, et al. AHA/ACCF Scientific statement on the evaluation of syncope. Circulation. 2006;113:316–327
2. Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M et al., Guidelines for the diagnosis and management of syncope (version 2009). European Heart Journal (2009); 30: 2631-2671.
3. Brignole M. Diagnosis and Treatment of Syncope. Heart 2007: 93; 130-136. Article PDF
4. Morag R, Brenner BE, Brown D. Syncope. June 27, 2012. Medscape Article.