Tackling syncope – a significant diagnostic challenge for many

Syncope–a transient loss of consciousness–occurs in 42% of people by the age of 70. Professor Richard Sutton, Emeritus Professor of Clinical Cardiology, discusses this common medical problem, and how he has pioneered a “true but still insufficiently small interest” in it.

I have been Emeritus Professor of Clinical Cardiology at Imperial since 2011. Prior to that, I had trained in Cardiology at St George’s Hospital, the University of North Carolina, and the National Heart Hospital in London, becoming Consultant Cardiologist at Westminster Hospital in 1976. There I focused on cardiac pacing as a subspecialty. From a clinical perspective, cardiac pacing eradicated syncope (transient loss of consciousness) in patients with conduction tissue disease of the heart. So, I sought to extend the role of pacing into related syncope conditions.

My primary interest therefore became the symptom of syncope. I began this in the late 1970s, and formed a close relationship with Worthing Hospital which carried a heavy load of older patients, many of whom presented syncope. I founded an outreach clinic at Worthing which led to the receipt of many challenging patients with syncope in whom there was no obvious cause.

Introducing tilt-testing

My team expanded to help me with this workload, allowing us to create a research programme that aimed to tackle these challenges. Notably, we introduced tilt-testing for the clinical diagnosis of the cause of syncope in 1986. My research colleague at that time was Rose Anne Kenny, now Regius Professor of Medicine at Trinity College, Dublin, and my most successful trainee to date.

Tilt-testing will reveal the cause of syncope in many older syncope patients where no diagnosis was clinically obvious, with the effect that they were typically ignored and went without any effective therapy. Tilt-testing remains widely practiced and is actually gaining traction again in Europe based on its value in precipitating asystole­–a condition in which the heart ceases to beat­–with its potential indication for benefit from pacing.

When Westminster Hospital closed in 1992, I moved to the new hospital, Chelsea and Westminster but the organisation did not want to take my sort of Cardiology seriously, resulting in my largely moving to the Brompton Hospital in 1993. There, I was a small fish in a big pool and research opportunities were curtailed. I took on other interests such as the Calman training scheme for specialist training. Until this innovation, UK had had no training scheme at all – everything was ad hoc. I felt that I had suffered from this, so I seized the opportunity to deliver the scheme in a fair and reasonable way. This was, of course, not popular with some but Cardiology had and still has far too few Cardiologists. At the outset in 1997, there were 57 persons in some form of training. I grew this number to 83 with a view to reducing the dearth of specialists in heart disease.

Expanding syncope research

After ‘normal’ retirement in 2005, I moved from the Brompton to St Mary’s at the request of my past trainees to found Imperial’s Syncope clinic. This quickly thrived and again, produced important work in the field of syncope albeit dominantly multicentre following the trend to deal in the much more convincing larger numbers of patients that a single unit can never achieve. On my ‘second’ retirement in 2011, Boon Lim took over as Syncope Clinic lead and became my successor resulting in the Clinic continuing to thrive. It has, of course, moved to the Hammersmith Campus with the rest of Cardiology.

I am now 83 but I continue my interest in syncope as Emeritus Professor at Imperial and Guest Professor of Cardiology at the University of Lund, Sweden, since 2018. In the last 12 years, from the second retirement, I have published 15-20 peer-reviewed papers every year now finding time to pursue research that I had no time to do as a full-time clinician. I am hoping to continue these activities for many years to come.

I have pioneered a true but still insufficient  interest in syncope, its diagnosis and management in the world. I hope that this will continue to expand for the benefit of the huge numbers that suffer this symptom – 40% of the population experiences at least one episode during a lifetime.

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