When should I consider referring a patient with syncope for cardiac evaluation, such as an ECG or echocardiogram?

Consider referring a patient with syncope for cardiac evaluation, including an electrocardiogram (ECG) or echocardiogram, if any of the following features are present:

• History or physical signs of heart failure.
• Syncope occurring during exertion.
• Family history of sudden cardiac death under age 40 or inherited cardiac conditions.
• New or unexplained breathlessness.
• Presence of a heart murmur.
• Age over 65 years with syncope without prodromal symptoms.

In these cases, refer within 24 hours for cardiovascular assessment including ECG and possibly echocardiography.

Additionally, if structural heart disease is suspected based on history or examination, cardiac imaging such as echocardiography should be performed to investigate further.

For suspected cardiac arrhythmic causes, ECG is essential, and ambulatory ECG monitoring may be indicated depending on syncope frequency.

Do not routinely refer for cardiac evaluation if the syncope is diagnosed as uncomplicated vasovagal, situational syncope, or postural hypotension without other concerning features.