The ‘ejection systolic murmur’

Differentiation between a benign flow murmur, aortic stenosis and subvalvular obstruction (ie. HOCM) can be difficult. As a rule a shorter (rather than a quieter) ejection systolic murmur is more likely to be benign. The murmur of HOCM is unusual in that it becomes louder on standing up (due to decreased venous return reducing the size of the heart). Echocardiography is a cheap, safe and readily available investigation and any patient with a murmur in the context of collapse warrants echocardiography.

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Any patient with a murmur in the context of collapse warrants echocardiography.

Exercise associated syncope

Exercise associated syncope is defined as syncope occurring during or immediately after exercise and accounts for 3 to 20% of cases of syncope. Patients with exercise associated syncope include groups of patients at high risk of sudden death. Serious causes to be considered include arrythmogenic right ventricular dysplasia, Brugada syndrome and HOCM. Although there can be pointers to these at presentation, there may not be: in all of these conditions the ECG may be normal or may show non-specific changes; and the murmur of HOCM may not always be heard.

The elderly patient with syncope

Syncope is increasingly common with increasing age and the great majority of patients presenting to the ED with syncope will be aged over 65. Older patients have a wide range of problems likely to cause syncope: there may be a poor baroreceptor response, there may be a degree of cardiac failure, and drugs that can cause syncope are commonly taken by the elderly. In addition, although neurocardiogenic syncope is more common in older patients, 10% of elderly patients without neurocardiogenic syncope have a positive tilt table test.


If a patient has had a typical, solitary vasovagal syncope while standing, with reliable prodrome, with a normal ECG and no clinical evidence of structural heart disease, they can keep driving and do not need to inform the DVLA.

For a further information see the full DVLA guidance.

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