Findings suggesting possible cardiac syncope in children and adolescents

History	Past medical history	Family history	Physical examination	Electrocardiogram
Syncope during exertion (including swimming)*	Congenital heart disease (corrected or uncorrected)*	Early cardiac death or sudden death in close relatives younger than 50 years of age*^¶	Pathologic murmur (eg, systolic ejection murmur with a click [aortic stenosis] or an outflow murmur that decreases with squatting or increases with Valsalva [HCM])*	Abnormal QT intervals*^Δ
Chest pain, or palpitations prior to or during the event*	Acquired heart disease with residual abnormal function*^◊	Familial arrhythmias*^¶	Signs of heart failure (eg, gallop, rales, hepatomegaly)*	Delta wave (ventricular pre-excitation or Wolff-Parkinson-White syndrome)*
Triggered by fright, anger, or auditory stimulus		Familial cardiomyopathy*^¶	Four limb blood pressure with systolic gradient (arm > leg) in patients with possible coarctation of aorta*^§	Excessive bradycardia or AV block*
Brief posturing or "seizure-like" event			Tachycardia (>95^th percentile for age)	Left axis deviation, prominent Q waves (leads II, III, and aVF), atrial enlargement with left ventricular hypertrophy, and/or deep inverted T waves (V₂ through V₄) indicating HCM*
No identifiable prodrome (eg, no lightheadedness, visual changes, or nausea)			Bradycardia (<5^th percentile for age)	Brugada syndrome (eg, pseudo-RBBB and ST elevation in V₁ to V₃ leads)*
			Irregular rhythm	Epsilon wave (arrhythmogenic right ventricular cardiomyopathy)*
				Signs of myocardial ischemia (eg, ST-T wave changes, Q waves)*^¥
				Findings of atrial enlargement and ventricular hypertrophy with ST segment and T wave abnormalities*

HCM: hypertrophic cardiomyopathy; AV: atrioventricular; RBBB: right bundle branch block.
* Patients with any one of these findings are more likely to have a cardiac cause for syncope. If present, consultation with a cardiologist with pediatric expertise is warranted. Findings without an asterisk are less specific and, by themselves, may not indicate a need for pediatric cardiology consultation if all other findings are normal.
¶ Applies to first degree (parents and siblings) and second degree (grandparents, uncle, aunt, half siblings) relatives.
Δ Prolonged hand-calculated corrected QT interval (eg, QTc >0.44 in males or >0.45 in adolescent females) or a short QT interval (≤0.30 sec).
◊ Eg, Kawasaki disease, rheumatic heart disease, myocarditis with cardiomyopathy.
§ A difference in the systolic measurement of 20 mmHg (arm greater than leg) is significant and suggests coarctation of the aorta.
¥ Refer to UpToDate topics on electrocardiogram in the diagnosis of myocardial ischemia and infarction.

Adapted and expanded from: Friedman KG, Alexander ME. Chest pain and syncope in children: A practical approach to the diagnosis of cardiac disease. J Pediatr 2013; 163:896.

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Findings suggesting possible cardiac syncope in children and adolescents