ECG AND THE SYNCOPAL PATIENT

• A careful examination of the ECG may reveal subtle clues to the possibility of a serious arrhythmia causing syncopal episodes
• An arrhythmia may not be evident but ECG may suggest a risk of ventricular arrhythmias, heart block or Torsade de pointes

Tachyarrhythmias

• AF
• Atrial flutter
• SVT
• VT/Torsades

Bradyarrhythmias

• Sinus pauses/Severe sinus bradycardia
• 2nd and 3rd degree heart block

Other clues

Abnormality	Predictive arrhythmia
Atrial fibrillation	Sick sinus syndrome (needs pacing) Rapid AF
ST/T changes of acute ischaemia/infarction	RV/posterior infarct - bradyarrhythmia LV infarct - tachyarrhythmia
QRS prolongation	Heart block
QT prolongation	Torsades
Pre-excitation (delta waves)	SVT, AF
Conduction abnormalities - PR prolongation/bundle branch block	Heart block
VPCs with R on T	VT
Multi-focal VPCs	VT
Non-capture of pacing spikes	Heart block