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Setting up and running an effective Syncope Service

Dr Boon Lim Cardiologist & Clinical Lead for Syncope Service at Imperial College Healthcare NHS Trust gave an extended presentation at today’s Syncope conference on: 

    • essential steps in setting up the service
    • how do we ensure early diagnosis: catching people at first episode of syncope
    • setting up and running an effective syncope service
    • communicating the service and increasing referrals
    • current challenges facing syncope services: consultation duration, prescribing off-license medications, clinical trials.

In his presentation Dr Lim commented;

"Syncope Specialist Nurses are key to a service

Taking a detailed history of a patient is key – clinical and also a paragraph or 2 about the symptoms.

Providing such detailed reporting can sometimes be straight forward

In the future my vision is a nurse led syncope service along side mine

Essentials to setting up a service

  • Understanding of the current service provisions within the trust – with an interest in syncope
    • Is there a falls clinic?
    • Is there a neurology clinic with an interest in syncope?
    • Is there a care of elderly specialist with an interest in syncope?
  • Understand the synergy/efficiency in different services – so that you are not sending the patient around and round to all services
  • Speak with colleagues who are already providing service to discuss management and referral pathways  
  • Understand the requirements of the service you are providing – mainly tilt-only service, syncope clinic services or an integrated service with MAU/A&E – this gets patient the appropriate diagnosis
  • Understanding finances – this is an important part for supporting your business case for tilt/syncope services  - we need to be the champion of the service

I cant emphasise enough the important of education – in early diagnosis

If you have 10 minutes with a patient you would probably be able to diagnosis them in 75% of cases

  • Taking a detailed history is key
  • Get an ecg
  • And do a risk stratification on the patient

An abnormal ecg is important to recognise

Providing a clear education in syncope for staff including front line staff is key

Make sure your service has clear visibility across the trust and appropriate referral pathways

Key challenges for the service are

  • Volume/consultation duration - Developing a good patient rapport and trusting relationship is key to effective management – they have to trust you
  • Training and management – how do you train a registrar who as on interest in syncope? So we have to build on individuals and try to get them interested in syncope.
    • The need for ratios are higher in syncope clinics – so you need management support
  • Medications – most medications have a poor evidence base for working with syncope (this makes it an incredible challenge) Drugs that do work/are evidence based are not licensed to prescribe for treating Syncope in the UK

Dr Lim's full presentation is available for download at the end of this page. 

Syncope is a common cause of admissions to the emergency room and to general practice, and usually results in numerous investigations at a significant healthcare cost. With a careful history and examination and a 12-lead ECG, patients can usually be effective risk-stratified for risk of sudden death. One important aspect of a syncope service at any institution is conducting appropriate training for front-line staff who are most likely to encounter syncope patients, which includes Emergency and Medical Admission Unit staff, and General Practitioners. This is the first medical contact for most patients with syncope and it is vital that patients are appropriately risk-stratified and managed accordingly afterwards. 

An effective syncope unit ideally provides a rapid-access syncope clinic pathway for patients, underpinned by staff who are confident and experienced in managing patients with syncope. Communication of service across the organisation, and to local general practitioners are key to increase referral to the syncope service. Good patient feedback to referring physicians also help to improve the profile and generate onward referrals. 

Some current challenges in management of severe vasovagal syncope include the lack of robust evidence base for most drug therapies, and the significant time it takes to establish rapport and build trust with patients, who have usually been seen by several different physicians, with numerous previous investigations. Patients come with a high expectations to any syncope unit. However, the initial treatment strategy for most patients are to get back to performing the "basics" properly and focus on conservative measures such as hydration, salt, isometric exercises, prior to institution of medical therapy (with poor evidence basis). These consultations, which aim to establish a clear clinical history, and equally importantly, build trust and rapport, does take more time than for other cardiology or general clinics, and usually result in follow-up consultations - which can be problematic for the busy clinician running a service that is close to breaching. Other challenges include prescribing off-license drugs such as midodrine and ivabradine, and managing the expectations of GPs, local pharmacists, and chief of service/general manager during the month-end drug budget spend audit for these non-approved drugs which can be beneficial in some patients. 

Well-conducted clinical trials form the basis for any evidence-based treatment, and there is an acknowledged difficulty in recruiting patients to these syncope trials. The Prevention of Syncope Trial (POST) trial (randomised placebo-controlled blinded controlled trial of beta blockers in syncope) recruited 208 patients from 5 countries, and took 5 years to conduct and 3 years to publish thereafter showing no benefit of beta blockers in syncope. The POST2 trial (RCT of fludrocortisone in syncope) started in 2005, and to-date has not been published, almost 10 years later. The POST 3 (pacemaker vs loop recorder in bifascicular block and syncope: registered 2011) and POST 4 (RCT of midodrine in syncope: registered 2012) may take as long to recruit and publish. The barriers to conducting clinical trials, including the major problem of recruiting to trials, will be discussed. 

Boon Lim is a consultant cardiologist and electrophysiologist at Imperial College Healthcare NHS Trust. He is the clinical lead for the Imperial Syncope Diagnostic Unit. Dr Lim graduated from Cambridge University in 2000, and trained in cardiology rotations at Oxford and North West London. He completed a PhD looking into the role of the autonomic nervous system in arrhythmogenesis at Imperial College London at St Mary's Hospital in 2010. Dr Lim took on the role of clinical lead for syncope at Imperial in 2011, where 650 tilt table tests are performed each year.
More information about Dr Boon Lim, and the Imperial Syncope Unit can be found at:

Download: Dr Boon Lim

4 November 2014


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