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Q1: Definition & classification (2 min)
- Define syncope and list the four required features that separate it from other causes of transient loss of consciousness.
- Reproduce the ESC 2018 mechanism-based classification: reflex (vasovagal, situational, carotid sinus), orthostatic hypotension (classical/initial/delayed; neurogenic vs non-neurogenic), and cardiac (arrhythmic vs structural).
- Distinguish syncope from seizure and psychogenic pseudosyncope at the bedside.
Examiner prompts: "What defines the mechanism — what does 'global' imply?" / "Why does unilateral carotid disease not cause syncope?"
Q2: Clinical assessment & investigations (3 min)
- Take a focused history from the patient and an eyewitness (the three 'witnessed collapse' questions: eyes open/closed, responsiveness, movement).
- Reproduce the high-risk features that mandate admission (exertional, supine, no prodrome, palpitations, abnormal ECG, structural heart disease, family history of SCD under 40).
- State the investigation that is mandatory in EVERY syncope patient and list the ECG findings you would actively look for.
- Reproduce the San Francisco Syncope Rule (CHEAT) and the Canadian Syncope Risk Score predictor variables; explain how each directs disposition.
- Describe the technique and diagnostic response of carotid sinus massage, including the absolute contraindications.
- State the threshold for orthostatic hypotension on active standing.
- Justify when you would request an implantable loop recorder versus a Holter monitor versus a tilt-table test.
Examiner prompts: "When is brain CT/EEG indicated — and when is it NOT?" / "What is the role of troponin and BNP in unexplained syncope?"
Q3: Management — mechanism-specific (3 min)
- Outline the ESC diagnostic pathway (initial evaluation → risk stratify → targeted investigation → treat the cause).
- Describe the lifestyle and pharmacological management of vasovagal syncope (hydration, salt, physical countermanoeuvres; midodrine and fludrocortisone as second-line; beta-blockers NOT recommended; pacing only in severe recurrent cardioinhibitory disease with documented asystole).
- Describe the management of orthostatic hypotension (stop culprit drugs, compression, salt/hydration, midodrine/fludrocortisone/droxidopa, manage supine hypertension).
- Describe the treatment of cardiac syncope by mechanism: pacing for AV block, ablation for SVT, ICD for channelopathies/cardiomyopathy/VT, AVR for aortic stenosis, myectomy/septal ablation for obstructive HCM.
- Reproduce the atropine dose and route for symptomatic bradycardia and the indications for emergent pacing.
- State the UK DVLA / Indian RTO driving advice after unexplained, vasovagal, and cardiac syncope (Group 1 vs Group 2).
Examiner prompts: "Why were the beta-blocker trials negative?" / "Why is a pacemaker not the answer for vasodepressor vasovagal syncope?"
Q4: Specific scenarios, pitfalls & prognosis (2 min)
- Explain why syncope in a young athlete is never normal and the conditions to exclude (HCM, ARVC, Brugada, LQTS, CPVT, anomalous coronary).
- Explain exertional syncope as a red flag for aortic stenosis, HCM, pulmonary hypertension, LQT1, CPVT.
- Distinguish the long-QT subtypes by trigger (LQT1 exertional/swimming; LQT2 auditory/emotional; LQT3 sleep).
- List the classic diagnostic pitfalls: mislabelling seizures as syncope; missing cardiac syncope with a 'normal' ECG; over-investigating with brain CT/EEG; missing drug-induced long QT; attributing collapse to 'vertebrobasilar insufficiency' without focal signs; dismissing elderly falls as mechanical.
- Quote the one-year mortality differential between cardiac, unexplained, and reflex syncope.
- State how you would manage the anticoagulated patient who has struck their head during syncope.
Examiner prompts: "What is the prognosis of vasovagal syncope in the young versus orthostatic syncope in the elderly?" / "Which score gives GRADUATED risk rather than a binary rule?"