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Collaborative working between cardiologists and neurologists should be encouraged for the benefit of patients with transient loss of consciousness
Dr Nasrin Khan, Dr Saqib Ahmad, Dr Janaka Pathiraja, Dr Francesco Manfredonia, Dr Sanjiv Petkar
New Cross Hospital, Wolverhampton, UK
Syncope, epilepsy, and psychogenic disorders are the three most common causes of transient loss of consciousness (TLoC), of which syncope is the most prevalent. Clinical presentation of all three are similar. In the majority, a complete history, physical examination, lying and standing blood pressure, and 12-lead electrocardiogram (ECG) help in arriving at a diagnosis. The National Institute for Health and Clinical Excellence (NICE) TLoC guidelines recommend first-stage assessment for all patients with TLoC, with selected patients undergoing second-stage assessment.
Our aim was to assess the prevalence of syncope in patients referred to a First Seizure Clinic and the type of syncope and management of such patients. We examined medical records for all patients (n=36) referred to TLoC clinic at a tertiary cardiology centre from a First Seizure Clinic (n=83) between April 2016 and March 2017 who had completed a minimum of one-year follow-up and who were assessed as per NICE TLOC Guidelines.
The mean age of patients (36 overall) was 41±16.5 years (median: 38; range: 28-54) and 58% (21) were male. Nine (25%) had a single episode of TLoC; 13 (36%) had variable frequency, and the remainder had about three episodes per month. After cardiology second-stage assessment, the provisional diagnosis of TLoC was as follows: reflex syncope (12); arrhythmogenic syncope (8); uncertain cause (10); epilepsy (5); migraine (1).
A high proportion (at least 25%) of patients with syncope were initially referred to a neurologist led First Seizure Clinic, following which they were appropriately redirected to cardiology. This referral pattern causes unnecessary delay in assessment, diagnosis and treatment and only increases patient anxiety and distress, while wasting scarce NHS resources. Education of referrers will help. This study also highlights the close collaborative working between cardiologists and neurologists at our centre and the appropriate application of second stage assessment of NICE TLoC guidelines for the benefit of patients.