Dr Lara Mitchell is a Consultant Geriatrician at Queen Elizabeth University Hospital (QEUH), Glasgow. She is clinical lead for acute and has developed a frailty service. She set up a syncope clinic in 2003 and now runs a weekly syncope clinic along with her Medicine for the Elderly colleague, Dr Anderton and has a joint MDT monthly with cardiology, neurology and cardiac physiologists. She is currently cohort 12 of Scottish quality and safety fellowship and is committed to improving systems of care for the older adult. She is current Chair of the BGS Cardiovascular SIG which is having its 24th Annual Meeting on 24 January in London. She tweets @laramit66043489
I have never written a blog before but was challenged to do this after we held a syncope morning at the last BGS Cardiovascular Meeting – ‘Brains & Hearts: Working Together’. Syncope is a symptom and not a diagnosis. It crosses many boundaries and hence different specialties are involved in the care of patients with syncope - cardiology, neurology and emergency medicine may all review these patients and, sadly, our orthopaedic colleagues may be involved when morbidity arises from recurrent undiagnosed episodes.
The history in patients presenting with syncope is the key to unlocking that diagnosis - a helpful question is “what was different that day”. Be pernickety about that history. Most of the time (70-80%) we can make the diagnosis - there are clues, symptoms and signs that give it away. Perhaps there is room for improvement in relaying this diagnosis to the patient. For the most part, patients will have a blood pressure problem (vasovagal syncope or orthostatic hypotension) and should have treatment tailored through medication review and giving guidance about the most up to date behavioural modifications that work and are evidence-based. For a proportion, the diagnosis will remain more elusive and their care is best under a specialist service, with experts who can coordinate their investigations and streamline the diagnosis. None of us want to miss that patient with a cardiac cause for their transient loss of consciousness. Older patients have an increased likelihood of having a cardiovascular cause so beware those patients without a prodrome or with a cardiac history or abnormal ECG - the index of suspicion should remain high.
A syncope MDT is made up of interested colleagues - we are fortunate enough to have cardiology, neurology and medicine for the elderly. Every month we meet (with coffee and good humour) and discuss those complex patients - learning from each other’s advice and wisdom to help plan the next step in investigations and likely diagnosis- perhaps asking the other specialty to see and sometimes seeing a patient together. For the most part, we look at tricky cardiac monitors and what is relevant to the diagnosis and I suspect we have all now learnt when to worry (grateful for friendly cardiologists!). We are taking on the mantle of each other, developing those other skills and perhaps turning into neurogericardiologists! We recently discussed a patient with severe aortic stenosis, pAF, orthostatic hypotension along with previous hypertension and mild dementia. What was the cause for her syncope? It all came down to making decisions together and realistic and person-centred medicine. I am convinced this delivers better and more organised care for those patients that are often a revolving door to unscheduled care. It’s completely rewarding and I would challenge you all to think about those pathways in your hospitals - do you have a way of seeing and coordinating care for those complex patients with syncope and do you have the right specialties involved?
Register now for the 24th Annual Cardiovascular SIG Meeting which is being held in London on 14 January 2020.