a b s t r a c t

Syncope is a frequent presenting complaint in the emergency department and is associated with significant Medical costs. We examined the utility of inPatient evaluation of syncope for patients in whom a diagnosis was not established in the emergency department. We retrospectively reviewed consecutive patients presenting with syncope to an urban tertiary care medical center. A diagnosis was not established after initial evaluation in the emergency department in 171 of 230 patients admitted. Inhospital evaluation led to a diagnosis in 26 patients. Acute intervention was required in 2 patients. Our observations suggest that an inpatient evaluation of syncope for patients in whom a diagnosis is not made on initial evaluation is of low yield, and outpatient follow-up may be safe.

(C) 2014

Introduction

Syncope is a sudden and transient loss of consciousness [1]. It is estimated to occur at least once in the lifetime of approximately 4% of the US population and is more common in the elderly [2,3]. The most common causes of syncope are well known and include a broad differential diagnosis. Cardiovascular causes account for 8% to 56% of episodes, whereas noncardiovascular etiologies are found in 17% to 72% of patients [3-12]. Despite extensive workup, the cause of syncope remains obscure in 13% to 47% of patients [4,5,9,13]. The variable proportion of causes among these studies has largely been influenced by patient selection. Initial history and physical examina- tion can be extremely important and were sufficient to determine a diagnosis in 21% to 85% of patients in whom a diagnosis was ultimately established, whereas routine electrocardiogram (ECG) yields an etiology in an additional 3% to 11% of patients [4-6,9,10,13].

Syncope can be challenging and even frustrating to physicians. The symptoms are nonspecific and may represent a wide gamut of pathology, varying from serious cardiovascular disorders to more benign neurologic, vasovagal, or psychogenic causes. Episodes are often infrequent and unwitnessed, making detailed descriptions of the events unattainable. Patients may have unremarkable physical and laboratory findings after or between episodes.

Syncopal events account for approximately 3% of emergency department (ED) visits and 6% of all medical hospital admissions, often to intensive care or telemetry units [4,5,14]. The medical

* Corresponding author. Department of Cardiology, Montefiore Medical Center, 111 East 210th St, 2nd Floor, Silver Zone, Bronx, NY 10467. Tel.: +1 718 702 4028; fax: +1 917 512 6692.

E-mail address: [email protected] (E.D. Manheimer).

expenditures associated with hospitalizations for syncope are significant with an annual cost of $2.4 billion [15]. The cost per hospitalization is variable with an estimated median cost of $8579, rising to $77 917 if an Implantable cardioverter defibrillator was placed [16]. Despite this aggressive use of resources, the yield of inhospital evaluation of syncope is modest, with hospitalization leading to a diagnosis in only 11% to 61% of patients [6,7,15]. A more cost-effective approach to the management of syncope is imperative in our climate of rising medical costs.

Although a growing body of literature illustrates the safety of an outpatient evaluation for syncope, the tendency to admit patients for further workup prevails [7,17,18]. The concern that acute, life- preserving intervention may be required drives the decision to admit patients. We reviewed the hospital course of patients presenting to an urban tertiary care medical center, which provides care to an underserved population with limited access to medical care and with an unreliable ability for outpatient care, for the purpose of describing the utility of inpatient evaluation of syncope and the need for acute interventions.

Methods

We retrospectively reviewed a consecutive series of patients who presented with syncope to the ED at The Albert Einstein College of Medicine-Montefiore Medical Center. We evaluated in detail the individual hospital records of 230 consecutive patients admitted to the hospital at the discretion of the treating ED physician. The medical records of these patients were reviewed for age, sex, comorbid illnesses, medications, events surrounding the syncopal event, emergency medical service documentation, physical examination findings, diagnostic tests, treatments, and length of hospital stay. The hospital course was reviewed, and significant clinical events were

http://dx.doi.org/10.1016/j.ajem.2014.06.015

0735-6757/(C) 2014

1114 E.D. Manheimer et al. / American Journal of Emergency Medicine 32 (2014) 1113–1116

documented. Acute intervention was defined as any pharmacologic or nonpharmacologic measure taken to reverse a potentially life- threatening condition. All patients underwent baseline testing that

Table 2

Patient demographics of patients admitted with and without a diagnosis for syncope established in the ED

included complete blood count, basic metabolic panel, and ECG. Subsequent tests were obtained at the discretion of the attending

Admitted with diagnosis (n = 59)

Admitted without diagnosis (n = 171)

physician caring for the patient.

Results

The initial evaluation in the ED yielded an etiology for the syncopal event in 59 of the 230 patients admitted (Table 1). These diagnoses

Age, mean +- SD (range) 70 +- 16 (24-98) 71 +- 15 (31-98)

Male sex, n (%) 23 (39.0) 65 (38.0)

Hypertension, n (%) 24 (40.7) 85 (49.7)

Diabetes mellitus, n (%) 14 (23.7) 21 (12.3)

Chronic kidney disease, n (%) 6 (10.2) 6 (3.5)

Coronary artery disease, n (%) 16 (27.1) 33 (19.3)

Myocardial infarction, n (%) 7 (11.9) 18 (10.5)

Stroke, n (%) 10 (16.9) 21 (12.3)

were made based largely on elicited history, ECG, laboratory testing,

Pacemaker/implantable

cardioverter defibrillator, n (%)

1 (1.7) 14 (8.2)

and diagnostic imaging. The remaining 171 patients were admitted without an established diagnosis. This group had a mean age of 71 +- 15 years (range, 31-98 years). Most of these patients were female (62%). Patient demographics are described in Table 2. Comorbid illnesses in patients without an ED diagnosis included hypertension in

85 patients (50%), coronary artery disease in 33 patients (19%), diabetes mellitus in 21 patients (12%), history of stroke in 21 patients (12%), and history of myocardial infarction in 18 patients (11%). Average length of hospital stay was 6.7 +- 4.6 days (range, 1-45 days) with initial admission to the telemetry unit in 82% of patients. Additional testing most often included serial cardiac markers, Holter recording, 2D echocardiography, head computed tomography, tilt- table test, carotid duplex, and electroencephalography.

During inpatient evaluation, a specific etiology for syncope was established in only 26 patients (15%). Cardiac and Noncardiac etiologies were diagnosed in 12 and 14 patients, respectively (Tables 3 and 4). The remaining 145 patients were discharged without a definitive diagnosis. Treatment resulting from the hospital evaluation of those admitted without an etiology for syncope was uncommon. Acute intervention occurred in only 2 patients (1%). Atropine and intrave- nous fluids were given to a 75-year-old man with bradycardia and hypotension on the fourth hospital day. He had a known neck mass and a history of radiotherapy. carotid sinus massage reproduced his findings along with presyncopal symptoms. Subsequent carotid angiography demonstrated left Common carotid artery compression. A 72-year-old man with hypertension, coronary artery disease, and congestive heart failure had an episode of nonsustained ventricular tachycardia on the second hospital day. Electrophysiology testing was recommended but declined by the patient. He later developed sustained ventricular tachycardia requiring direct current cardiover- sion and amiodarone on the 26th hospital day. No specific therapy was given to 139 patients (81%). Empiric treatment for a presumed

diagnosis was ordered for 9 patients (5%).

Supraventricular tachycardia, n (%) 8 (13.6) 13 (7.6)

Congestive heart failure, n (%) 10 (16.9) 11 (6.9)

Valvular heart disease, n (%) 0 5 (2.9)

seizure disorder, n (%) 3 (5.1) 3 (1.8)

Discussion

Our study demonstrates the limited yield of further inhospital evaluation for patients in whom a diagnosis is not made in the ED and that life-threatening events rarely occur during a patient’s hospital- ization. A diagnosis was established by the time of discharge in only an additional 15% of patients. This is similar to the rates of diagnosis described by Kapoor et al [19] and Mozes et al [10]. Although some studies report a higher rate of diagnoses made, comparison is difficult. Shiyovich et al [7] found an established diagnosis in approximately half of patients but do not distinguish whether this was the result of the inpatient testing or from the initial ED evaluation. Although just 13% of patients remained undiagnosed in the study by Day et al [4], evaluation occurred over a lengthier follow-up of a mean of 11 months. Similarly, the greater percentage of established etiologies by Brignole et al [13] was achieved with a 45-day follow-up. Silverstein et al [5] revealed an established diagnosis in 53% of patients but with a markedly different population. They evaluated patients admitted to the medical intensive care unit for syncope as opposed to all-comers to the ED.

Morag et al [17] prospectively examined 34 patients admitted after nondiagnostic ED evaluations and found that none were given a definitive diagnosis or required acute interventions during

Table 3

Diagnostic evaluation and therapy of patients with cardiac etiology of syncope (n = 12)

Diagnosis Diagnostic test

Test results Number Therapy

Table 1

Etiology of syncope based on initial ED evaluation (n = 59)

Atrial fibrillation/ flutter

EPS Inducible and sustained atrial

6 Permanent pacemaker

Cardiovascular etiology Patients (%)

Noncardiovascular etiology

Patients (%)

Sick sinus

flutter/fibrillation with block

EPS Inducible atrial

Permanent

Bradycardia 4 (6.8) Orthostatic hypotension 9 (15.3)

syndrome

fibrillation with sinus

pacemaker

Ventricular tachycardia/fibrillation

4 (6.8) Vasovagal 8 (13.6)

arrest on termination Bradycardia Telemetry Bradycardia with

Permanent

Myocardial infarction 3 (5.1) Hypoglycemia 7 (11.9)

Supraventricular tachycardia 3 (5.1) drug induced 6 (10.2)

3- to 5-s pauses

pacemaker (refused by

Atrial fibrillation/flutter 2 (3.4) Gastrointesinal

hemorrhage

3 (5.1)

Stokes-Adams

EPS HV interval

1 patient)

1 Permanent

Stroke 2 (3.4) Alcohol induced 2 (3.4)

Cardiac arrest 1 (1.7) Seizure disorder 1 (1.7)

attack Carotid sinus

Carotid

grossly prolonged Complete heart block

pacemaker

2 Permanent

Ruptured Abdominal aortic aneurysm

1 (1.7) Micutration/situational syncope

1 (1.7)

hypersensitivity

sinus massage

with hypotension

pacemaker (1), no

intervention (1)

Abbreviation: EPS, electrophysiology.

Cardiomyopathy	1 (1.7)	Sepsis	1 (1.7)
Total	21 (35.6)	Total	38 (64.4)

E.D. Manheimer et al. / American Journal of Emergency Medicine 32 (2014) 1113–1116 1115

Table 4

Diagnostic evaluation and therapy of patients with Noncardiac etiology of syncope (n = 14)

In summary, inhospital evaluation of syncope is of low yield, and life-threatening conditions requiring emergent, acute intervention are

Diagnosis Diagnostic test

Test results Number Therapy

infrequent. In view of the low morbid event rate in our population of hospitalized patients, our data suggest that early outpatient

Vasovagal Tile table Hypotension and

reproduction of symptoms

10 ?-blocker (9)

Fludrocortisone (2)

Disopyramide (1)

evaluation and follow-up would be safe in most patients in whom an ED evaluation fails to establish an etiology for syncope. Despite these favorable findings, discretion on the part of ED physicians is

Gastrointestinal

hemorrhage

Seizure disorder

Endoscopy Gastritis (1)

and prepyloric ulcer (1)

EEG Temporal lobe dysfunction

2 Proton-pump

inhibitor (2) Heater probe coagulation (1)

2 Dilantin (2)

imperative when managing patients with an unclear etiology for syncope as populations with higher risk for adverse events may still warrant inpatient evaluation, albeit with a limited yield. high-risk features include recent myocardial infarction, systolic heart failure, documented malignant arrhythmia, and acute anemia. In the absence

Abbreviation: EEG, electroencephalogram.

hospitalization. In a retrospective study of 302 patients admitted for syncope, Maung et al [18] found that the clinically relevant yield of testing was less than 5%. Although this inpatient workup led to intervention in 14%, there were no acute interventions.

Tilt-table test was performed in 33 of our patients and yielded a diagnosis of vasovagal syncope in 10 patients. Although the protocols vary among studies, tilt-table testing has been found to be positive in up to 71% of patients [20-22]. An additional 8 patients were found to have a cardiac cause of syncope based on electrophysiologic studies. Abnormalities at electrophysiologic study has been found in 29% to 71% of patients admitted for syncope, with inducible ventricular tachycardia in up to 50% of these patients [8,9,22-29].

Hospitalization of Patients with syncope is frequently advocated because of concern for morbidity and mortality. The reported mortality associated with syncope ranges considerably and is likely explained by the variation in the extent of underlying cardiac pathology and the acuity of the studied populations. The overall mortality rate at 12 months is in the range of 8% to 14% [7,8]. Mortality is greater when there is a cardiac cause for syncope [5,7,8]. The Inhospital mortality is far lower and shown in a large database of more than 300 000 patients to be less than 1% [16].

Acute intervention was required in only 2 of our patients: 1 with a neck mass and 1 with ventricular tachycardia. Carotid sinus syncope associated with a neck mass has been previously described [30]. Our patient with malignant cervical adenopathy experienced 11 hypo- tensive episodes in 3 days during spontaneous rightward head turning. Symptoms resolved after intracranial resection of the left glossopharyngeal nerve and upper rootlets of the left vagus nerve. In a study of carotid sinus syncope, right-sided hypersensitivity was more frequent than left-sided hypersensitivity and was accompanied by a prodrome in only 30% of patients. Symptoms are often reproduced by carotid sinus massage during head-up tilt-table testing [31].

Although our institution does not have a syncope observation unit, such units have been demonstrated to reduce hospital admissions [13,32]. Algorithms to guide diagnostic testing and decisions for admission have been shown to further limit hospital admissions [33]. Although these algorithms are promising, they are computer based and have limited applicability to common practice at this time.

We recognize limitations to our retrospective study. Although this single center study limits the ability to make generalizations, our institution has the second busiest ED in the United States with 294 056 visits in 2011 and consists of a very diverse population [34]. Our data are limited to patients admitted from the ED. The data on patients discharged from the ED are, therefore, not available, and we do not know the frequency of established diagnoses or outcomes of those patients not admitted. Review of the Clinical courses of the admitted patients was limited to the duration of the inhospital stay, and long- term and outpatient follow-ups are lacking. We acknowledge that there may be psychosocial reasons among patients with syncope, especially in the elderly, that warrant admission.

of such features, patients with nondiagnostic and benign evaluations may be appropriate for close outpatient follow-up. This more thoughtful selection of patients for outpatient workup would allow more efficient use of medical resources.

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