Reviewed on : 29 May 2026

Reviewed by : Geeta Paul

Expires : 29 May 2028

Recurrent and Cardiac Syncope Service POTS Clinic

Referral criteria and checklist for referring clinicians

Purpose: This document provides guidance for clinicians referring patients to the recurrent and cardiac syncope service. It outlines strict referral criteria to support appropriate  referral decisions for patients presenting with recurrent, unexplained or cardiac syncope, and to streamline clinic triage

Please note: Not Intended for isolated simple vasovagal episodes

Referral Criteria

Age limit for 18 years and over (with exceptions for patients aged 16-18, considered only on exceptional circumstances)

Strict diagnostic criteria:

Patient’s must meet ALL of the following criteria for review:

• Detailed history (circumstances, prodromal, recovery)
• Standing or seated loss of consciousness
• Detailed history of fluid intake
• Lying & standing Blood pressure

Required Pre-Referral Investigations:

• 12 lead ECG (only when clinically indicated)
• Orthostatic vital signs (lying and standing heart rate & blood pressure at 5 minutes)
• Blood test full blood count, urea and electrolytes and thyroid function (TSH)
• Medication list, agents affecting heart rate or blood pressure
• Brief symptoms summary including duration, frequency and functional impact
• Review of medications (such as antihypertensives, diuretics, beta-blockers)

(Referrals from other tertiary hospitals please provide relevant clinic letters confirming diagnosis including tilt test reports attached to the referral)

High risk patients:  Unexplained syncope / Seated LOC / exertional syncope / No provoking factors / abnormal ECG / background of significant cardiac conditions / family history of sudden cardiac death ***Refer URGENTLY to syncope clinic***

Suggested Pre -referral management:

Low risk patients:  Syncope coinciding with  Vasovagal syncope / Reflex mediated / Orthostatic intolerance (not intended for isolated vasovagal episode) prodrome / provoking factors, normal ECG / No seated loss of consciousness or cardiac history or significant family history of sudden cardiac death***Referral NOT required – please follow the lifestyle modification plan advice below***

Lifestyle Modification Plan

• Encourage adequate hydration 2-3 L daily front load in the beginning of the morning
• Limit consumption of caffeine/alcohol (trigger dehydration)
• Include isotonic and mineral based drinks such as milk, smoothies pure juices cordials
• Increase dietary salt intake (10 g daily)
• Advice avoidance of prolonged standing, dehydration and heat exposure
• Lower recumbent calf clench exercises to prevent venous pooling
• Consider compression garments waist-high or (abdominal binders)

Other useful resources:  STARS (Syncope Trust and Reflex anoxic Seizures) www.stars.org.uk

Referral checklist:

Please ensure all boxes are ticked before referral:

☐ Lying and standing blood pressure & heart rate  (upto 5 minutes)

☐ Recent ECG (only when clinically indicated) and  blood tests (FBC, U&e, TFT)

☐ Detailed symptom summary provided including a good fluid history