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November 11, 1992, Vol 268, No. 18 >
ARTICLE | November 11, 1992

Evaluation and Management of the Patient With Syncope FREE

Wishwa N. Kapoor, MD, MPH
[+] Author Affiliations

This article is one of a series sponsored by the American Heart Association.

Reprint requests to Room 100, Lothrop Hall, 190 Lothrop St, Pittsburgh, PA 15261 (Dr Kapoor).


JAMA. 1992;268(18):2553-2560. doi:10.1001/jama.1992.03490180085031
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Published online
Article
References

Objective.  —To review the studies on diagnostic evaluation of syncope and to provide an approach to the diagnostic testing and management of this condition.

Data Source.  —Published studies on the evaluation of syncope in the English language.

Study Selection.  —Cohort studies and case series of patients presenting with syncope and focused studies of various diagnostic tests such as prolonged electrocardiographic monitoring, electrophysiologic studies, and upright tilt testing. Specific selection criteria were used in the case of prolonged electrocardiographic monitoring, in which all studies had to have performed at least 12 hours of monitoring.

Data Extraction.  —Studies reviewed by the author.

Data Synthesis.  —Studies in the 1980s have shown that a cause of syncope is not diagnosed in as many as 47% of the patients presenting with this symptom. When a cause of syncope is established, a history and physical examination lead to the identification of 56% to 85% of the causes. In the remaining patients, arrhythmia detection is a central issue. A major problem with the use of ambulatory electrocardiographic (Holter) monitoring in the diagnosis of arrhythmias is that symptomatic correlation with arrhythmias is rarely found (only 4% of patients). Increasing the duration of monitoring from 24 to 72 hours does not lead to increased yield of symptomatic arrhythmias. Patient-activated intermittent loop recorders that can be worn for several weeks may occasionally show a symptomatic correlation, but they are most useful in patients with multiple recurrences of syncope. Electrophysiologic studies are more likely to be abnormal in patients with underlying heart disease or those who have abnormalities on surface electrocardiogram. The most common abnormality found on electrophysiologic studies is inducible ventricular tachycardia. Upright tilt testing has been used to induce vasovagal syncope in patients with syncope of unknown cause. A positive response has been found in 26% to 87% of patients undergoing this type of testing. The specificity of this test needs to be further investigated. In patients with recurrent syncope of unknown cause, psychiatric evaluation should also be pursued for illnesses such as generalized anxiety disorder, panic disorder, somatization, and major depression.

Conclusions.  —A directed approach to the evaluation is possible using the studies on diagnostic testing of syncope.(JAMA. 1992;268:2553-2560)

REFERENCES

1 +
Lipsitz LA, Wei JY, Rowe JW.  Syncope in an elderly, institutionalized population: prevalence, incidence, and associated risk. Q J Med . 1985;;55:45-55.
2 +
Kapoor WN. Hypotension and syncope. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine . Philadelphia, Pa: WB Saunders Co; 1991;:875-886.
3 +
Ross RT. Syncope . Philadelphia, Pa: WB Saunders Co; 1988;.
4 +
Kapoor W, Karpf M, Wieand S, Peterson J, Levey G.  A prospective evaluation and follow-up of patients with syncope. N Engl J Med . 1983;;309:197-204.
5 +
Kapoor W.  Evaluation and outcome of patients with syncope. Medicine . 1990;;69:160-175.
6 +
Eagle KA, Black HR.  The impact of diagnostic tests in evaluating patients with syncope. Yale J Biol Med . 1983;;56:1-8.
7 +
Silverstein MD, Singer DE, Mulley A, Thibault GE, Barnett GO.  Patients with syncope admitted to medical intensive care units. JAMA . 1982;;248:1185-1189.
8 +
Martin GJ, Adams SL, Martin HG, Matthews J, Zull D, Scanlon PJ.  Prospective evaluation of syncope. Ann Emerg Med . 1984;;13:499-504.
9 +
Day SC, Cook EF, Funkenstein H, Goldman L.  Evaluation and outcome of emergency room patients with transient loss of consciousness. Am J Med . 1982;;73:15-23.
10 +
Kenny RA, Ingram A, Bayliss J, Sutton R.  Head-up tilt: a useful test for investigating unexplained syncope. Lancet . 1986;;1:1352-1355.
11 +
Fitzpatrick AP, Theodorakis G, Vardas P, Sutton R.  Methodology of head-up tilt testing in patients with unexplained syncope. J Am Coll Cardiol . 1991;;17:125-130.
12 +
Strasberg B, Rechavia E, Sagie A, et al.  The head-up tilt table test in patients with syncope of unknown origin. Am Heart J. 1989;;118( (5 pt 1) ):923-927.
13 +
Raviele A, Gasparini G, DiPede F, Delise P, Bonso A, Piccolo E.  Usefulness of head-up tilt test in evaluating patients with syncope of unknown origin and negative electrophysiologic study. Am J Cardiol . 1990;;65:1322-1327.
14 +
Abi-Samra FM, Maloney JD, Fouad-Tarazi FM, Castle LW.  The usefulness of head-up tilt testing and hemodynamic investigations in the work-up of syncope of unknown origin. PACE Pacing Clin Electrophysiol . 1987;;10:406.
15 +
Brignole M, Menozzi C, Gianfranchi L, Oddone D, Lolli G, Bertulla A.  Carotid sinus massage, eyeball compression, and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J . 1991;;122:1651-1664.
16 +
Almquist A, Goldenberg IF, Milstein S, et al.  Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med . 1989;;320:346-351.
17 +
Sra JS, Anderson AJ, Sheikh SH, et al.  Unexplained syncope evaluated by electrophysiologic studies and head-up tilt testing. Ann Intern Med . 1991;;114:1013-1019.
18 +
Grubb BP, Temesy-Armos P, Hahn H, Elliott L.  Utility of upright tilt table testing in the evaluation and management of syncope of unknown origin. Am J Med . 1991;;90:6-10.
19 +
Pongigline G, Fish FA, Strasburger JF, Benson DW.  Heart rate and blood pressure response to upright tilt in young patients with unexplained syncope. J Am Coll Cardiol . 1990;;16:165-170.
20 +
Kapoor WN, Brant NL.  Evaluation of syncope by upright tilt testing with isoproterenol: a nonspecific test. Ann Intern Med . 1992;;116:358-363.
21 +
Linzer M, Felder A, Hackel A, Maria I, Melville MI, Krishnan KR.  Psychiatric syncope. Psychosomatics . 1990;;31:181-188.
22 +
Kapoor W, Peterson J, Wieand HS, Karpf M.  Diagnostic and prognostic implications of recurrences in patients with syncope. Am J Med . 1987;; 83:700-708.
23 +
Hoefnagels WAJ, Padberg GW, Overweg J, van der Velde EA, Roos RAC.  Transient loss of consciousness: the value of the history for distinguishing seizure from syncope. J Neurol . 1991;;238: 39-43.
24 +
Kapoor WN, Peterson JR, Karpf M.  Micturition syncope. JAMA . 1985;;253:796-798.
25 +
Kapoor W, Peterson J, Karpf M.  Defecation syncope: a symptom with multiple etiologies. Arch Intern Med . 1986;;146:2377-2379.
26 +
Kapoor WN.  Diagnostic evaluation of syncope. Am J Med . 1991;;90:91-106.
27 +
Fields WS, Lemak NA.  Joint study of extracranial arterial occlusion, VII: subclavian steal—a review of 168 cases. JAMA . 1972;;222:1139-1143.
28 +
Swanson JW, Vick NA.  Basilar artery migraine. Neurology . 1978;;28:782-786.
29 +
Atkins D, Hanusa B, Sefcik T, Kapoor W.  Syncope and orthostatic hypotension. Am J Med . 1991;; 91:179-185.
30 +
Strasberg B, Sagie A, Erdman S, Kusniec J, Sclarvosky S, Agmon J.  Carotid sinus hypersensitivity and the carotid sinus syndrome. Prog Cardiovasc Dis . 1989;;5:379-391.
31 +
Jonas S, Klein I, Dimant J.  Importance of Holter monitoring in patients with periodic cerebral symptoms. Ann Neurol . 1977;;1:470-474.
32 +
Boudoulas H, Schaael SF, Lewis RP, Robinson JL.  Superiority of 24-hour outpatient monitoring over multi-stage exercise testing for the evaluation of syncope. J Electrocardiol . 1979;;12:103-108.
33 +
Clark PI, Glasser SP, Spoto E.  Arrhythmias detected by ambulatory monitoring: lack of correlation with symptoms of dizziness and syncope. Chest . 1980;;77:722-725.
34 +
Zeldis SM, Levine BJ, Michelson EL, Morganroth J.  Cardiovascular complaints: correlation with cardiac arrhythmias on 24-hour electrocardiographic monitoring. Chest . 1980;;78:456-462.
35 +
Kala R, Viitasalo MT, Toivonen L, Eisalo A.  Ambulatory ECG recording in patients referred because of syncope or dizziness. Acta Med Scand. 1982;;668( (suppl JC:14K) ):13-19.
36 +
Gibson TC, Heitzman MR.  Diagnostic efficacy of 24-hour electrocardiographic monitoring for syncope. Am J Cardiol . 1984;;53:1013-1017.
37 +
Bass EB, Curtiss El, Arena VC, et al.  The duration of Holter monitoring in patients with syncope: is 24 hours enough? Arch Intern Med . 1990;; 150:1073-1078.
38 +
DiMarco JP, Philbrick JT.  Use of ambulatory electrocardiographic (Holter) monitoring. Ann Intern Med . 1990;;113:53-68.
39 +
Linzer M, Pritchett ELC, Pontinen M, McCarthy E, Divine GW.  Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope. Am J Cardiol . 1990;;66:214-219.
40 +
DiMarco JP, Garan H, Harthorne JW, Ruskin JN.  Intracardiac electrophysiology techniques in recurrent syncope of unknown cause. Ann Intern Med . 1981;;95:542-548.
41 +
Gulamhusein S, Naccarelli GV, Ko PT, et al.  Value and limitations of clinical electrophysiologic study in assessment of patients with unexplained syncope. Am J Med . 1982;;73:700-705.
42 +
Hess DS, Morady F, Scheinman MM.  Electrophysiologic testing in the evaluation of patients with syncope of undetermined origin. Am J Cardiol . 1982;;50:1309-1315.
43 +
Akhtar M, Shenasa M, Denker S, Gilbert CJ, Rizwi N.  Role of cardiac electrophysiologic studies in patients with unexplained recurrent syncope. PACE Pacing Clin Electrophysiol . 1983;;6:192-201.
44 +
Olshansky B, Mazuz M, Martins JB.  Significance of inducible tachycardia in patients with syncope of unknown origin: a long-term follow-up. J Am Coll Cardiol . 1985;;5:216-233.
45 +
Doherty JU, Pembrook-Rogers D, Grogan EW, et al.  Electrophysiologic evaluation and follow-up characteristics of patients with recurrent unexplained syncope and presyncope. Am J Cardiol . 1985;;55:703-708.
46 +
Teichman SL, Felder SD, Matos JA, Kim SG, Waspe LE, Fisher JD.  The value of electrophysiologic studies in syncope of undetermined origin: report of 150 cases. Am Heart J . 1985;;110:469-479.
47 +
Denes P, Vretz E, Ezri MD, Borbola J.  Clinical predictors of electrophysiology findings in patients with syncope of unknown origin. Arch Intern Med . 1988;;148:1922-1928.
48 +
Bass EB, Elson JJ, Fogoros RN, Peterson J, Arena VC, Kapoor WN.  Long-term prognosis of patients undergoing electrophysiologic studies for syncope of unknown origin. Am J Cardiol. 1988;; 62:1186-1191.
49 +
Krol RB, Morady F, Flaker GC, et al.  Electrophysiologic testing in patients with unexplained syncope: clinical and noninvasive predictors of outcome. J Am Coll Cardiol . 1987;;10:358-363.
50 +
Kapoor WN, Hammill SC, Gersh BJ.  Diagnosis and natural history of syncope and the role of invasive electrophysiologic testing. Am J Cardiol . 1989;;63:730-734.
51 +
Linzer M, Prystowsky EN, Divine GW, et al.  Predicting the outcomes of electrophysiologic studies of patients with unexplained syncope. J Gen Intern Med . 1991;;6:113-120.
52 +
Bachinsky WB, Linzer M, Weld L, Estes NA.  Usefulness of clinical characteristics in predicting the outcome of electrophysiologic studies in unexplained syncope. Am J Cardiol . 1992;;69:1044-1049.
53 +
Click RL, Gersh BJ, Sugrue DD, et al.  Role of invasive electrophysiologic testing in patients with symptomatic bundle branch block. Am J Cardiol . 1987;;59:817-823.
54 +
Nelson SD, Kou WH, DeBuitleir M, DiCarlo LA, Morady F.  Value of programmed ventricular stimulation in presumed carotid sinus syndrome. Am J Cardiol . 1987;;60:1073-1077.
55 +
McLaran CJ, Gersh BJ, Osborn MJ, et al.  Increased vagal tone as an isolated finding in patients undergoing electrophysiologic testing for recurrent syncope: response to long-term anticholinergic agents. Br Heart J . 1986;;55:53-57.
56 +
Hammill SC, Holmes DR, Wood DL, et al.  Electrophysiologic testing in the upright position: improved evaluation of patients with rhythm disturbances using a tilt table. J Am Coll Cardiol . 1984;; 4:65-71.
57 +
Morady F, Scheinman MM.  The role and limitations of electrophysiologic testing in patients with unexplained syncope. Int J Cardiol . 1983;;4: 229-234.
58 +
Fujimura O, Yee R, Klein GJ, Sharma AD, Boahene HK.  The diagnostic sensitivity of electrophysiologic testing in patients with syncope caused by transient bradycardia. N Engl J Med . 1989;;321: 1703-1707.
59 +
DiMarco JP.  Electrophysiologic studies in patients with unexplained syncope. Circulation . 1987;; 75( (suppl III) ):III-140-III-143.
60 +
McAnulty JH.  Syncope of unknown origin: the role of electrophysiologic studies. Circulation . 1987;; 75( (suppl III) ):III-144-III-145.
61 +
DiMarco JP, Garan H, Ruskin JN.  Complications in patients undergoing cardiac electrophysiologic procedure. Ann Intern Med. 1982;;97:490-493.
62 +
Health and Public Policy Committee, American College of Physicians.  Diagnostic endocardial electrical recording and stimulation. Ann Intern Med . 1984;;100:452-454.
63 +
Gang ES, Peter T, Rosenthal ME, Mandel WJ, Lass Y.  Detection of late potentials on the surface electrocardiogram in unexplained syncope. Am J Cardiol . 1986;;58:1014-1020.
64 +
Winters SL, Stewart D, Gomes JA.  Signal averaging of the surface QRS complex predicts inducibility of ventricular tachycardia in patients with syncope of unknown origin: a prospective study. J Am Coll Cardiol . 1987;;10:775-781.
65 +
Mark AL.  The Bezold-Jarisch reflex revisited: clinical implications of inhibitory reflexes originating in the heart. J Am Coll Cardiol . 1983;;1:90-92.
66 +
Abboud FM.  Ventricular syncope. N Engl J Med . 1989;;320:390-392.
67 +
Waxman MB, Yao L, Cameron DA, Wald RW, Roseman J.  Isoproterenol induction ofvasodepressor-type reaction in vasodepressor-prone patients. Am J Cardiol . 1989;;63:58-65.
68 +
Milstein S, Buetikofer J, Dunnigan A, Benditt DG, Gornick C, Reyes WJ.  Usefulness of disopyramide for prevention of upright tilt-induced hypotension-bradycardia. Am J Cardiol . 1990;;65:1339-1344.
69 +
Benditt DG, Benson W, Kreitt J, et al.  Electrophysiologic effects of theophylline in young patients with recurrent symptomatic bradyarrhythmias. Am J Cardiol . 1983;;52:1223-1229.
70 +
Nelson SD, Stanley M, Love CJ, Coyne KS, Schall SF.  The autonomic and hemodynamic effects of oral theophylline in patients with vasodepressor syncope. Arch Intern Med . 1991;;151:2425-2429.
71 +
Fitzpatrick A, Theodorakis G, Ahmed R, Williams T, Sutton T.  Dual chamber pacing aborts vasovagal syncope induced by head-up 60° tilt. PACE Pacing Clin Electrophysiol . 1991;;14:13-19.
72 +
Kapoor W, Fortunato M, Sefcik T, Schulberg H.  Psychiatric illnesses in patients with syncope. Clin Res . 1989;;37:316A.
73 +
Kapoor W, Karpf M, Maher Y, Miller R, Levey G.  Syncope of unknown origin: the need for a more cost-effective approach to its diagnostic evaluation. JAMA . 1982;;247:2687-2691.
74 +
Davis TL, Freeman FR.  Electroencephalography should not be routine in the evaluation of syncope in adults. Arch Intern Med . 1990;;150:2027-2029.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Lipsitz LA, Wei JY, Rowe JW.  Syncope in an elderly, institutionalized population: prevalence, incidence, and associated risk. Q J Med . 1985;;55:45-55.
2 +
Kapoor WN. Hypotension and syncope. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine . Philadelphia, Pa: WB Saunders Co; 1991;:875-886.
3 +
Ross RT. Syncope . Philadelphia, Pa: WB Saunders Co; 1988;.
4 +
Kapoor W, Karpf M, Wieand S, Peterson J, Levey G.  A prospective evaluation and follow-up of patients with syncope. N Engl J Med . 1983;;309:197-204.
5 +
Kapoor W.  Evaluation and outcome of patients with syncope. Medicine . 1990;;69:160-175.
6 +
Eagle KA, Black HR.  The impact of diagnostic tests in evaluating patients with syncope. Yale J Biol Med . 1983;;56:1-8.
7 +
Silverstein MD, Singer DE, Mulley A, Thibault GE, Barnett GO.  Patients with syncope admitted to medical intensive care units. JAMA . 1982;;248:1185-1189.
8 +
Martin GJ, Adams SL, Martin HG, Matthews J, Zull D, Scanlon PJ.  Prospective evaluation of syncope. Ann Emerg Med . 1984;;13:499-504.
9 +
Day SC, Cook EF, Funkenstein H, Goldman L.  Evaluation and outcome of emergency room patients with transient loss of consciousness. Am J Med . 1982;;73:15-23.
10 +
Kenny RA, Ingram A, Bayliss J, Sutton R.  Head-up tilt: a useful test for investigating unexplained syncope. Lancet . 1986;;1:1352-1355.
11 +
Fitzpatrick AP, Theodorakis G, Vardas P, Sutton R.  Methodology of head-up tilt testing in patients with unexplained syncope. J Am Coll Cardiol . 1991;;17:125-130.
12 +
Strasberg B, Rechavia E, Sagie A, et al.  The head-up tilt table test in patients with syncope of unknown origin. Am Heart J. 1989;;118( (5 pt 1) ):923-927.
13 +
Raviele A, Gasparini G, DiPede F, Delise P, Bonso A, Piccolo E.  Usefulness of head-up tilt test in evaluating patients with syncope of unknown origin and negative electrophysiologic study. Am J Cardiol . 1990;;65:1322-1327.
14 +
Abi-Samra FM, Maloney JD, Fouad-Tarazi FM, Castle LW.  The usefulness of head-up tilt testing and hemodynamic investigations in the work-up of syncope of unknown origin. PACE Pacing Clin Electrophysiol . 1987;;10:406.
15 +
Brignole M, Menozzi C, Gianfranchi L, Oddone D, Lolli G, Bertulla A.  Carotid sinus massage, eyeball compression, and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J . 1991;;122:1651-1664.
16 +
Almquist A, Goldenberg IF, Milstein S, et al.  Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med . 1989;;320:346-351.
17 +
Sra JS, Anderson AJ, Sheikh SH, et al.  Unexplained syncope evaluated by electrophysiologic studies and head-up tilt testing. Ann Intern Med . 1991;;114:1013-1019.
18 +
Grubb BP, Temesy-Armos P, Hahn H, Elliott L.  Utility of upright tilt table testing in the evaluation and management of syncope of unknown origin. Am J Med . 1991;;90:6-10.
19 +
Pongigline G, Fish FA, Strasburger JF, Benson DW.  Heart rate and blood pressure response to upright tilt in young patients with unexplained syncope. J Am Coll Cardiol . 1990;;16:165-170.
20 +
Kapoor WN, Brant NL.  Evaluation of syncope by upright tilt testing with isoproterenol: a nonspecific test. Ann Intern Med . 1992;;116:358-363.
21 +
Linzer M, Felder A, Hackel A, Maria I, Melville MI, Krishnan KR.  Psychiatric syncope. Psychosomatics . 1990;;31:181-188.
22 +
Kapoor W, Peterson J, Wieand HS, Karpf M.  Diagnostic and prognostic implications of recurrences in patients with syncope. Am J Med . 1987;; 83:700-708.
23 +
Hoefnagels WAJ, Padberg GW, Overweg J, van der Velde EA, Roos RAC.  Transient loss of consciousness: the value of the history for distinguishing seizure from syncope. J Neurol . 1991;;238: 39-43.
24 +
Kapoor WN, Peterson JR, Karpf M.  Micturition syncope. JAMA . 1985;;253:796-798.
25 +
Kapoor W, Peterson J, Karpf M.  Defecation syncope: a symptom with multiple etiologies. Arch Intern Med . 1986;;146:2377-2379.
26 +
Kapoor WN.  Diagnostic evaluation of syncope. Am J Med . 1991;;90:91-106.
27 +
Fields WS, Lemak NA.  Joint study of extracranial arterial occlusion, VII: subclavian steal—a review of 168 cases. JAMA . 1972;;222:1139-1143.
28 +
Swanson JW, Vick NA.  Basilar artery migraine. Neurology . 1978;;28:782-786.
29 +
Atkins D, Hanusa B, Sefcik T, Kapoor W.  Syncope and orthostatic hypotension. Am J Med . 1991;; 91:179-185.
30 +
Strasberg B, Sagie A, Erdman S, Kusniec J, Sclarvosky S, Agmon J.  Carotid sinus hypersensitivity and the carotid sinus syndrome. Prog Cardiovasc Dis . 1989;;5:379-391.
31 +
Jonas S, Klein I, Dimant J.  Importance of Holter monitoring in patients with periodic cerebral symptoms. Ann Neurol . 1977;;1:470-474.
32 +
Boudoulas H, Schaael SF, Lewis RP, Robinson JL.  Superiority of 24-hour outpatient monitoring over multi-stage exercise testing for the evaluation of syncope. J Electrocardiol . 1979;;12:103-108.
33 +
Clark PI, Glasser SP, Spoto E.  Arrhythmias detected by ambulatory monitoring: lack of correlation with symptoms of dizziness and syncope. Chest . 1980;;77:722-725.
34 +
Zeldis SM, Levine BJ, Michelson EL, Morganroth J.  Cardiovascular complaints: correlation with cardiac arrhythmias on 24-hour electrocardiographic monitoring. Chest . 1980;;78:456-462.
35 +
Kala R, Viitasalo MT, Toivonen L, Eisalo A.  Ambulatory ECG recording in patients referred because of syncope or dizziness. Acta Med Scand. 1982;;668( (suppl JC:14K) ):13-19.
36 +
Gibson TC, Heitzman MR.  Diagnostic efficacy of 24-hour electrocardiographic monitoring for syncope. Am J Cardiol . 1984;;53:1013-1017.
37 +
Bass EB, Curtiss El, Arena VC, et al.  The duration of Holter monitoring in patients with syncope: is 24 hours enough? Arch Intern Med . 1990;; 150:1073-1078.
38 +
DiMarco JP, Philbrick JT.  Use of ambulatory electrocardiographic (Holter) monitoring. Ann Intern Med . 1990;;113:53-68.
39 +
Linzer M, Pritchett ELC, Pontinen M, McCarthy E, Divine GW.  Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope. Am J Cardiol . 1990;;66:214-219.
40 +
DiMarco JP, Garan H, Harthorne JW, Ruskin JN.  Intracardiac electrophysiology techniques in recurrent syncope of unknown cause. Ann Intern Med . 1981;;95:542-548.
41 +
Gulamhusein S, Naccarelli GV, Ko PT, et al.  Value and limitations of clinical electrophysiologic study in assessment of patients with unexplained syncope. Am J Med . 1982;;73:700-705.
42 +
Hess DS, Morady F, Scheinman MM.  Electrophysiologic testing in the evaluation of patients with syncope of undetermined origin. Am J Cardiol . 1982;;50:1309-1315.
43 +
Akhtar M, Shenasa M, Denker S, Gilbert CJ, Rizwi N.  Role of cardiac electrophysiologic studies in patients with unexplained recurrent syncope. PACE Pacing Clin Electrophysiol . 1983;;6:192-201.
44 +
Olshansky B, Mazuz M, Martins JB.  Significance of inducible tachycardia in patients with syncope of unknown origin: a long-term follow-up. J Am Coll Cardiol . 1985;;5:216-233.
45 +
Doherty JU, Pembrook-Rogers D, Grogan EW, et al.  Electrophysiologic evaluation and follow-up characteristics of patients with recurrent unexplained syncope and presyncope. Am J Cardiol . 1985;;55:703-708.
46 +
Teichman SL, Felder SD, Matos JA, Kim SG, Waspe LE, Fisher JD.  The value of electrophysiologic studies in syncope of undetermined origin: report of 150 cases. Am Heart J . 1985;;110:469-479.
47 +
Denes P, Vretz E, Ezri MD, Borbola J.  Clinical predictors of electrophysiology findings in patients with syncope of unknown origin. Arch Intern Med . 1988;;148:1922-1928.
48 +
Bass EB, Elson JJ, Fogoros RN, Peterson J, Arena VC, Kapoor WN.  Long-term prognosis of patients undergoing electrophysiologic studies for syncope of unknown origin. Am J Cardiol. 1988;; 62:1186-1191.
49 +
Krol RB, Morady F, Flaker GC, et al.  Electrophysiologic testing in patients with unexplained syncope: clinical and noninvasive predictors of outcome. J Am Coll Cardiol . 1987;;10:358-363.
50 +
Kapoor WN, Hammill SC, Gersh BJ.  Diagnosis and natural history of syncope and the role of invasive electrophysiologic testing. Am J Cardiol . 1989;;63:730-734.
51 +
Linzer M, Prystowsky EN, Divine GW, et al.  Predicting the outcomes of electrophysiologic studies of patients with unexplained syncope. J Gen Intern Med . 1991;;6:113-120.
52 +
Bachinsky WB, Linzer M, Weld L, Estes NA.  Usefulness of clinical characteristics in predicting the outcome of electrophysiologic studies in unexplained syncope. Am J Cardiol . 1992;;69:1044-1049.
53 +
Click RL, Gersh BJ, Sugrue DD, et al.  Role of invasive electrophysiologic testing in patients with symptomatic bundle branch block. Am J Cardiol . 1987;;59:817-823.
54 +
Nelson SD, Kou WH, DeBuitleir M, DiCarlo LA, Morady F.  Value of programmed ventricular stimulation in presumed carotid sinus syndrome. Am J Cardiol . 1987;;60:1073-1077.
55 +
McLaran CJ, Gersh BJ, Osborn MJ, et al.  Increased vagal tone as an isolated finding in patients undergoing electrophysiologic testing for recurrent syncope: response to long-term anticholinergic agents. Br Heart J . 1986;;55:53-57.
56 +
Hammill SC, Holmes DR, Wood DL, et al.  Electrophysiologic testing in the upright position: improved evaluation of patients with rhythm disturbances using a tilt table. J Am Coll Cardiol . 1984;; 4:65-71.
57 +
Morady F, Scheinman MM.  The role and limitations of electrophysiologic testing in patients with unexplained syncope. Int J Cardiol . 1983;;4: 229-234.
58 +
Fujimura O, Yee R, Klein GJ, Sharma AD, Boahene HK.  The diagnostic sensitivity of electrophysiologic testing in patients with syncope caused by transient bradycardia. N Engl J Med . 1989;;321: 1703-1707.
59 +
DiMarco JP.  Electrophysiologic studies in patients with unexplained syncope. Circulation . 1987;; 75( (suppl III) ):III-140-III-143.
60 +
McAnulty JH.  Syncope of unknown origin: the role of electrophysiologic studies. Circulation . 1987;; 75( (suppl III) ):III-144-III-145.
61 +
DiMarco JP, Garan H, Ruskin JN.  Complications in patients undergoing cardiac electrophysiologic procedure. Ann Intern Med. 1982;;97:490-493.
62 +
Health and Public Policy Committee, American College of Physicians.  Diagnostic endocardial electrical recording and stimulation. Ann Intern Med . 1984;;100:452-454.
63 +
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To understand the clinical management of acute heart failure syndromes.
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Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
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AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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