100 QUESTIONS IN CARDIOLOGY

75 How should I investigate the patient with

collapse? Who should have a tilt test, and what do

I do if it is positive?

RA Kenny and Diarmuid O’Shea

Investigation of a patient with collapse

The history from the older patient may be less reliable, however a

careful history often allows syncopal episodes to be classified into

broad diagnostic categories (Table 75.1). Elderly patients may

have amnesia for their collapse. A witness history, available in

only 40–60% of cases, can thus be invaluable. Witnessed features

of prodrome (i.e. pallor, sweating, loss of consciousness or fitting)

and clinical characteristics after the event can all help in building

a diagnostic picture. Physical examination should include an

assessment of blood pressure in the supine and erect position, a

cardiovascular examination to look for the presence or absence of

structural heart disease (including aortic stenosis, mitral stenosis,

outflow tract obstruction, atrial myxoma or impaired left

ventricular function) and auscultation for carotid bruits. The 12-

lead electrocardiogram (ECG) remains an important tool in the

diagnosis of arrhythmic syncope. Up to 11% of syncopal patients

have a diagnosis assigned from their ECG. More importantly

those with a normal 12-lead ECG (no QRS or rhythm distur-

bance) have a low likelihood of arrhythmia as a cause of their

syncope and are at low risk of sudden death. Thus the history and

physical examination can guide you as to the more appropriate

diagnostic tests for the individual patient and would include the

following:

• ECG


• 24 hour ECG


• 24 hour BP


• Carotid sinus massage – supine and erect (only if negative

supine)

• External loop recorder


• Electrophysiological studies


• Head up tilt test


• CT head and EEG if appropriate


• Implantable loop recorder