American Academy of Pediatrics – Section on Cardiology and Cardiac Surgery

View all recommendations from this society

Released November 2, 2020

Do not order an echocardiogram for the routine evaluation of pediatric syncope in the absence of a concerning history or ECG abnormalities.

Syncope is a common complaint in pediatrics and is rarely caused by a cardiac issue in patients with a normal physical examination. If the episode is caused by the heart, it generally is an issue with the heart rhythm. Therefore, an echocardiogram rarely adds diagnostic value and it increases cost of care. In situations in which an echocardiogram may be warranted, (syncope that occurs in the circumstance of an abnormal ECG, exertional syncope, unexplained postexertional syncope, or syncope in the setting of a concerning family history,* consultation with a pediatric cardiologist is recommended prior to obtaining the echocardiogram. Therefore, it is important to obtain a thorough personal and family history,* physical examination, and ECG when indicated prior to proceeding with echocardiography in the initial assessment of pediatric syncope.

*Family history should assess specifically for the following types of cardiovascular diseases:
– Connective tissue disorders
– Cardiomyopathies
– Arrhythmias, including need for pacemaker or defibrillator implantation
– Storage diseases
– Sudden unexplained death
– Premature cardiovascular disease prior to the age of 50 years

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items
on this list or their individual situation should consult their physician.

How The List Was Created

This list was developed initially by faculty in Pediatric Cardiology at University Hospitals in Cleveland OH. It was then revised and approved by the AAP Section on Cardiology and Cardiac Surgery. After review by other AAP sections, the AAP Executive Committee granted final approval of the list.

AAP’s disclosure and conflict of interest policy can be found at


Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R. ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate use criteria for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol. 2014;64(19):2039-2060

Phelps HM, Kelleman MS, McCracken CE, et al. Application of pediatric appropriate use criteria for initial outpatient evaluation of syncope. Echocardiography. 2017;34(3):441-445
Pelletier JH, Blanchard S, Chamberlain RC, Hornik CP, Campbell MJ, Hill KD. The use of echocardiography for pediatric patients presenting with syncope. J Pediatr. 2017;190:43-48