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* | |
Loss of consciousness followed by brief posturing or "seizure-like" event | Tachycardia (>95th percentile for age) in the absence of noncardiac causes such as fever, pain, or anemia¥ | 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 (<5th 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*‡ |
AV: atrioventricular; HCM: hypertrophic cardiomyopathy; 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 content on causes of tachycardia in children.
‡ Refer to UpToDate topics on electrocardiogram in the diagnosis of myocardial ischemia and infarction.