Red flags – Consider admission/urgent referral:

·         Syncope during exertion/supine

·         Syncope associated with unexplained chest pain, breathlessness or back pain

·         Family history sudden death (<40years) or significant  inheritable cardiac condition

·         Known pacemaker/defibillator to exclude malfunction

·         Ongoing hypotension, bradycardia or tachycardia

·         Clinical signs of aortic stenosis, HOCM, heart failure, tamponade or dissection

·         ECG abnormalities e.g. infarct/ischaemic change , LVH/strain pattern, AV block, LBBB, RBBB, trifascicular block, new arrhythmias, long QT >450ms, corrected short QT <350ms, short PR with delta wave, paced rhythms


Consider referral to a General Cardiology Clinic for:

·         Recurrent episodes

·         History or family history indicative of a cardiac cause

·         Sustained an injury or are at risk of sustaining injury

·         Had an episode at wheel of car

·         Features suggestive of carotid hypersensitivity eg on head turning/neck pressure

·         Abnormal cardiovascular examination eg a murmur

·         Abnormal ECG 


Consider referral to Care of the Elderly:

(Unless there is a strong indicator of significant arrhythmias or structural heart disease)

·         Syncope of unknown cause in those >65 years

·         Those with multiple co-morbidites/ polypharmacy


Consider referral to Neurology:

(Unless there is a strong indicator of significant arrhythymias or structural heart disease)

·         Preceding aura/generalised seizure activity/ tongue biting

·         Prolonged recovery

·         Associated neurological symptoms/ signs

·         Symptoms in keeping with known neurological process


A referral may not be appropriate if:

Patients have symptoms in keeping with orthostatic hypotension who have a normal examination and a normal ECG.


Prior to referral:

Recent FBC, U+E

Please ensure a recent 12 lead ECG is attached

Reference / further reading

NICE,ESC, map of medicine, 10




Date reviewed                     05/07/2021

Next review due                  05/07/2022

Sifter name                         Elizabeth Fell / Bridgitte Wesson

Contributors                        Dr Louise Melley – Assistant Specialist Cardiology RCHT


Version 2.1