Diagnosis and Management of Syncope in Elderly Males

Etiology and Epidemiology

The European Society of Cardiology recommends that orthostatic hypotension, cardiac arrhythmias, and reflex syncope be considered as the most common causes of syncope in elderly males, with these conditions frequently coexisting in the same patient 1
Orthostatic hypotension is the leading cause of syncope in elderly males, with hospitalization rates increasing from 4.2% in 65-74 year-olds to 30.5% in those over 75 years, according to the European Heart Journal 1
The American College of Cardiology states that arrhythmias represent the most common cardiac cause of syncope in the elderly, including sick sinus syndrome, Mobitz II block, high-grade AV block, and complete heart block 3, 2
The European Heart Journal reports that cardioinhibitory carotid sinus syndrome is the recognized cause of symptoms in up to 20% of elderly patients with syncope 1

A detailed history focusing on timing, medication review, witness account, cognitive status, social circumstances, and impact on activities of daily living is essential for diagnosis, as recommended by the European Heart Journal 1, 6
Physical examination including supine and upright blood pressure measurements, cardiovascular exam, neurological and locomotor assessment, and gait and balance observation is crucial for diagnosis, according to the European Heart Journal 1, 4, 6
The European Heart Journal suggests that 12-lead ECG looking for conduction abnormalities, QT prolongation, signs of ischemia, ventricular ectopy, or arrhythmias should be performed as part of the initial evaluation 6
Routine carotid sinus massage at first assessment in elderly patients is recommended by the European Heart Journal, even if non-specific carotid sinus hypersensitivity is frequent without history of syncope 4

The European Heart Journal recommends that medication review and withdrawal of potentially causative agents can reduce recurrence of syncope and falls in elderly patients 1
The American College of Cardiology states that implantable loop recorders are especially useful in elderly patients with unexplained syncope due to the high frequency of arrhythmias 4
The European Heart Journal suggests that tilt testing is well tolerated and safe in the elderly, with positivity rates similar to younger patients, particularly after nitroglycerin challenge 4