Syncope, Presyncope & Palpitations
Separate benign reflex/orthostatic causes from arrhythmic, structural and other high-risk causes that require urgent investigation.
Module format: each study session covers what to learn, how the presentation appears clinically, investigation/management priorities, safety issues and common MCCQE traps.
Module 9 — Topic map
- Initial syncope history, witness history, orthostatic vitals, cardiovascular/neurologic examination and ECG
- Vasovagal/reflex syncope and common triggers
- Orthostatic hypotension, volume depletion and medication-related syncope
- Arrhythmic syncope: red flags, conduction disease and inherited electrical disorders
- Structural causes including aortic stenosis and hypertrophic cardiomyopathy
- Differentiating syncope from seizure, hypoglycemia and psychogenic events
- Palpitations: ECG, Holter/event monitoring and when symptoms require urgent referral
- Disposition: who can be reassured, observed, admitted or referred
Assessment / DiagnosisAcute CareRisk / dispositionECG monitoring
Study Session 9.1 — Initial Syncope Assessment & Risk Stratification
Focused MCCQE cardiovascular study session
Core topics & learning goals
- Take event, prodrome, posture, exertion, trigger, recovery and witness history.
- Perform orthostatic vitals, cardiac/neurologic exam and ECG.
- Identify red flags: exertional/supine syncope, abnormal ECG, structural disease, family sudden death, chest pain or palpitations.
- Differentiate true syncope from seizure, fall and metabolic causes.
Clinical recognition & investigation
- Assess injury and anticoagulation consequences.
- Use targeted rather than routine neuroimaging when no neurologic indication exists.
Management & patient-safety priorities
- Admit/urgent refer high-risk cardiac syncope; reassure/manage benign reflex syncope appropriately.
- Review medications and hydration.
MCCQE exam traps
- Routine head CT is not required for uncomplicated syncope without trauma/focal neurology.
- Absence of prodrome can be a cardiac red flag.
Study Session 9.2 — Vasovagal, Orthostatic & Non-Cardiac Mimics
Focused MCCQE cardiovascular study session
Core topics & learning goals
- Recognize typical vasovagal triggers/prodrome and rapid recovery.
- Diagnose orthostatic hypotension and identify dehydration, autonomic and medication causes.
- Differentiate syncope from seizure using tongue injury, postictal state, prolonged confusion and witness description.
- Consider hypoglycemia and psychogenic events when appropriate.
Clinical recognition & investigation
- Review antihypertensives, diuretics and psychoactive drugs.
- Assess volume status and autonomic symptoms.
Management & patient-safety priorities
- Use trigger avoidance, hydration, counter-pressure strategies and medication review.
- Treat underlying volume or autonomic cause.
MCCQE exam traps
- Brief myoclonic movements can occur during syncope and do not prove epilepsy.
- Do not attribute recurrent syncope to vasovagal causes when high-risk features are present.
Study Session 9.3 — Palpitations & Ambulatory Monitoring
Focused MCCQE cardiovascular study session
Core topics & learning goals
- Characterize sudden versus gradual onset, regularity, duration, triggers and associated syncope/chest pain.
- Use ECG, electrolytes, thyroid studies and CBC selectively.
- Select Holter, event monitor or longer monitoring based on symptom frequency.
- Recognize red flags requiring urgent cardiology assessment.
Clinical recognition & investigation
- Differentiate ectopy, sinus tachycardia, SVT, AF and ventricular arrhythmia clues.
- Assess stimulant/caffeine/substance and medication contributors.
Management & patient-safety priorities
- Treat the rhythm/cause and address lifestyle triggers when benign.
- Urgently evaluate palpitations with syncope, structural disease or concerning ECG.
MCCQE exam traps
- A normal ECG between episodes does not exclude paroxysmal arrhythmia.
- Do not order a 24-hour Holter for very infrequent symptoms and expect high yield.