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Click on boxes to expand/collapse detailed information.               Characterize symptoms                                                                     Medication history                                                           Past medical history                                                           Possible triggers                                                           Physical examination                                                           Labs and tests                                                           Imaging studies                                                           Diagnostic features                                                                                         Syncope                   Non syncope loss of consciousness                                                                     Known etiology ❑ Cardiovascular ❑ Orthostatic hypotension ❑ Reflex         Unknown etiology Determine if there are any high risk criteria:         Consider additional tests                                                                             High risk       low risk   Consider alternative diagnoses                                                                               Immediate in-hospital monitoring       Recurrent syncopes       Single syncope                                                                             If suspicion of structural hear disease: Order an echocardiography           Was it in high risk setting? ❑ Potential risk of physical injury ❑ Occupational implications                                                                                                                 Structural heart disease present Treat accordingly         No structural heart disease   Yes   No: No further evaluation                                                                                               Tilt testing

Characterize symptoms ❑ Loss of consciousness (LOC) ❑ Rapid or slow onset ❑ Short or long duration ❑ Spontaneous complete recovery or incomplete recovery ❑ Prodrome: ❑ Diaphoresis ❑ Nausea ❑ Lightheadedness ❑ Pallor ❑ Warmth ❑ Blurry vision ❑ Chest pain (suggestive of cardiovascular syncope) ❑ Palpitations ❑ Position prior to LOC: ❑ Supine (suggestive of cardiovascular syncope) ❑ Supine to erect posture (suggestive of orthostatic hypotension or reflex syncope) ❑ Prolonged standing (suggestive of reflex syncope) ❑ Activity prior to LOC: (suggestive of cardiovascular or reflex syncope) ❑ Driving ❑ Machine operation ❑ Flying ❑ Competitive athletics ❑ Bowel or bladder incontinence (suggestive of reflex syncope)

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Inquire about medications intake:
❑ Nitrates
❑ Diuretics
❑ Antiarrhythmic
❑ Alpha blocker
❑ Beta blocker
❑ ACE inhibitors or ARB
❑ Hydralazine
❑ Ethanol
❑ Benzodiazepines
❑ Antipsychotics
❑ Tricyclic antidepressants
❑ Barbiturates

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Obtain a detailed past medical history:
❑ Previously healthy
❑ Previous syncope episodes

❑ Time since previous episode

❑ Number of previous episodes

❑ Cardiovascular disease:

❑ Arrhythmia

❑ Heart block (LBBB, RBBB)

❑ Valvular heart disease

❑ Heart failure

❑ Hypertrophic cardiomyopathy

❑ Cardiac tumor

❑ Neurological diseases:

❑ Parkinson's disease

❑ Diabetic neuropathy

❑ Metabolic disorders (diabetes) ❑ Recent trauma

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Identify possible triggers:
Suggestive of reflex syncope
❑ Emotional stress
❑ Crowded places (agoraphobia)
❑ Warm weather
❑ Prolonged standing
❑ Cough
❑ Micturition
❑ Defecation
❑ Swallowing
❑ Head motion
❑ Arm motion
❑ Shaving

Suggestive of cardiovascular or orthostatic hypotension
❑ Trauma
❑ Change in position
❑ Fatigue
❑ Exertion

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Examine the patient Vitals
❑ Heart rate

❑ Irregular rhythm (suggestive of AF)

❑ Tachycardia (suggestive of orthostatic hypotension, cardiovascular or reflex syncope)

❑ Bradycardia (suggestive of cardiovascular syncope)

❑ Blood pressure:

❑ Measure in both arms, while standing and supine

❑ Orthostatic hypotension (Fall in systolic BP ≥ 20 mmHg and/or in diastolic BP of at least≥ 10 mmHg between the supine and sitting BP reading)

❑ Hypertension (suggestive of cardiovascular syncope)

❑ Respiratory rate

❑ Tachypnea (suggestive of reflex syncope)

Respiratory
❑ Rales (suggestive of HF)

Cardiovascular
❑ Palpitations (suggestive of arrhythmia)
❑ Carotid bruits (suggestive of cardiovascular syncope)
❑ Murmurs:

❑ Aortic stenosis: crescendo-decrecendo systolic ejection murmur best heard at the upper right sternal border

❑ Pulmonary stenosis: systolic ejection murmur best heard at the left second intercostal space

❑ Heart sounds

❑ Loud P2 (suggestive of pulmonary hypertension)

Neurologic
❑ Focal abnormalities (suggestive of stroke or cerebral mass)

❑ Hemiparesis

❑ Vision loss

❑ Aphasia

❑ Hypertonia

❑ Glasgow coma scale
❑ Signs suggestive of Parkinson's disease:

❑ Tremor

❑ Rigidity

❑ Bradykinesia/Akinesia

❑ Postural instability

❑ Shuffling gait

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Drug	Adult dosage
Inhaled Short Acting β Agonists (SABA)
Albuterol/Bitolterol/Pirbuterol a) Nebulizer solution b) MDI	♦ 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed or 10-15 mg/hour continuously. ♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Levalbuterol a) Nebulizer solution b) MDI	♦ 1.25-2.5 mg every 20 mins for 3 doses, then 1.25-5 mg every 1-4 hours as needed. ♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Anticholinergics
Ipratropium bromide a) Nebulizer solution b) MDI	♦ 0.5 mg every 20 mins for 3 doses, then as needed. ♦ 8 puffs every 20 mins as needed for upto 3 hours.
Ipratropium with albuterol a) Nebulizer solution (each 3 ml containing 0.5 mg ipratropium and 2.5 mg albuterol) b) MDI (each puff contains 18 mcg ipratropium and 90 mcg albuterol)	♦ 3 ml every 20 mins for 3 doses, then as needed. ♦ 8 puffs every 20 mins as needed for 3 hours
Systemic corticosteroids
Prednisone/Prednisolone/Methylprednisolone	♦ 40-80 mg/day in 1 or 2 divided doses until peak expiratory flowrate (PEF) reaches 70% of personal best.

Clinical course	Unstable
Physical examination	Signs of heart failure
Functional class	IV
6MWD	Less than 400 m
Echocardiogram	RV Enlargement
Hemodynamics	RAP high CI low
BNP	Elevated/Increasing
Treatment	Intravenous prostacyclin and/or combination treatment
Frequency of evaluation	Q 1 to Q 3 months
FC assessment	Every clinic visit
6MWT	Every clinic visit
Echocardiogram2	Q 6 to Q 12 months/center dependent
BNP	center dependent
RHC	Q 6 to Q 12 months or clinical deterioration