Did This Patient Have Cardiac Syncope?: The Rational Clinical Examination Systematic Review

Wearable ECG patch monitoring for 72 h is comparable to conventional Holter monitoring for 24 h to detect cardiogenic vertigo

We sought to compare the diagnostic efficacy of a 72-hour wearable electrocardiography (ECG) patch monitoring with a conventional 24-hour Holter monitoring for the detection of cardiogenic vertigo. We conducted a prospective multicenter study that recruited 47 patients suspected of cardiogenic vertigo in four referral-based university hospitals between November 2019 and April 2022. Patients received simultaneous ambulatory ECG recordings using a 72-hour wearable ECG patch monitoring and a conventional 24-hour Holter monitor. The primary outcome was the detection rate of arrhythmia events during the entire wearing period. The secondary outcomes included device preference and factors affecting the detection of cardiogenic vertigo. During the 72-hour monitoring period, there was no significant difference in the overall detection rate of arrhythmia events between the wearable patch and conventional Holter monitoring (10 of 47 [21.3%] vs. 8 of 47 [17.0%], p = .500) Most patients (46/47) favored a wearable patch over Holter monitoring. The effectiveness of wearable ECG patch monitoring was comparable to conventional Holter monitoring in detecting cardiogenic vertigo. With its extended monitoring capability and patient preference, wearable patch monitoring holds promise as an alternative method for the diagnosis of cardiogenic vertigo. Limitations of this study include small sample size and selection bias.

Syncope in the Emergency Department: A Practical Approach

Syncope is a common condition encountered in the emergency department (ED), accounting for about 0.6-3% of all ED visits. Despite its high frequency, a widely accepted management strategy for patients with syncope in the ED is still missing. Since syncope can be the presenting condition of many diseases, both severe and benign, most research efforts have focused on strategies to obtain a definitive etiologic diagnosis. Nevertheless, in everyday clinical practice, a definitive diagnosis is rarely reached after the first evaluation. It is thus troublesome to aid clinicians' reasoning by simply focusing on differential diagnoses. With the current review, we would like to propose a management strategy that guides clinicians both in the identification of conditions that warrant immediate treatment and in the management of patients for whom a diagnosis is not immediately reached, differentiating those that can be safely discharged from those that should be admitted to the hospital or monitored before a final decision. We propose the mnemonic acronym RED-SOS: Recognize syncope; Exclude life-threatening conditions; Diagnose; Stratify the risk of adverse events; Observe; decide on the Setting of care. Based on this acronym, in the different sections of the review, we discuss all the elements that clinicians should consider when assessing patients with syncope.

Does this patient have Clostridioides difficile infection? A systematic review and meta-analysis

BACKGROUND

The clinical features and predictors of Clostridioides difficile infection overlap with many conditions.

OBJECTIVES

We performed a systematic review to evaluate the diagnostic utility of clinical features (clinical examination, risk factors, laboratory tests, and radiographic findings) associated with C. difficile.

METHODS

Systematic review and meta-analysis of diagnostic features for C. difficile.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched up to September 2021.

STUDY ELIGIBILITY CRITERIA

Studies that reported clinical features of C. difficile, a valid reference standard test for confirming diagnosis of C. difficile, and a comparison among patients with a positive and negative test result.

PARTICIPANTS

Adult and paediatric patients across diverse clinical settings.

OUTCOMES

Sensitivity, specificity, likelihood ratios.

REFERENCE STANDARD

Stool nucleic acid amplification tests, enzyme immunoassays, cell cytotoxicity assay, and stool toxigenic culture.

ASSESSMENT OF RISK OF BIAS

Rational Clinical Examination Series and Quality Assessment of Diagnostic Accuracy Studies-2.

METHODS OF DATA SYNTHESIS

Univariate and bivariate analyses.

RESULTS

We screened 11 231 articles of which 40 were included, enabling the evaluation of 66 features for their diagnostic utility for C. difficile (10 clinical examination findings, 4 laboratory tests, 10 radiographic findings, prior exposure to 13 antibiotic types, and 29 clinical risk factors). Of the ten features identified on clinical examination, none were significantly clinically associated with increased likelihood of C. difficile infection. Some features that increased likelihood of C. difficile infection were stool leukocytes (LR+ 5.31, 95% CI 3.29-8.56) and hospital admission in the prior 3 months (LR+ 2.14, 95% CI 1.48-3.11). Several radiographic findings also strongly increased the likelihood of C. difficile infection like ascites (LR+ 2.91, 95% CI 1.89-4.49).

DISCUSSION

There is limited utility of bedside clinical examination alone in detecting C. difficile infection. Accurate diagnosis of C. difficile infection requires thoughtful clinical assessment for interpretation of microbiologic testing in all suspected cases.

Strategies to mitigate emergency department crowding and its impact on cardiovascular patients

Emergency department (ED) crowding is a worsening global problem caused by hospital capacity and other health system challenges. While patients across a broad spectrum of illnesses may be affected by crowding in the ED, patients with cardiovascular emergencies-such as acute coronary syndrome, malignant arrhythmias, pulmonary embolism, acute aortic syndrome, and cardiac tamponade-are particularly vulnerable. Because of crowding, patients with dangerous and time-sensitive conditions may either avoid the ED due to anticipation of extended waits, leave before their treatment is completed, or experience delays in receiving care. In this educational paper, we present the underlying causes of crowding and its impact on common cardiovascular emergencies using the input-throughput-output process framework for patient flow. In addition, we review current solutions and potential innovations to mitigate the negative effect of ED crowding on patient outcomes.

Predictive value of EGSYS score in the differential diagnosis of cardiac syncope and neurally mediated syncope in children

Background and objective

Syncope is a common emergency with diverse etiologies in children. Among these, cardiac syncope (CS) is associated with high mortality and is usually difficult to diagnose. However, there is still no validated clinical prediction model to distinguish CS from other forms of pediatric syncope. The Evaluation of Guidelines in Syncope Study (EGSYS) score was designed to identify CS in adults and has been validated in several studies. In this study, we aimed to assess the ability of the EGSYS score in predicting CS in children.

Methods

In this retrospective study, we calculated and analyzed the EGSYS scores of 332 children hospitalized for syncope between January 2009 and December 2021. Among them, 281 were diagnosed with neurally mediated syncope (NMS) through the head-up tilt test, and 51 were diagnosed with CS using electrocardiography (ECG), echocardiography (ECHO), coronary computed tomography angiography (CTA), myocardial enzymes and genetic screening. The receiver operating characteristic (ROC) curve and Hosmer-Lemeshow test were used to evaluate the predictive value of the EGSYS score system.

Results

The median scores of 51 children with CS and 281 children with NMS were 4 [interquartile range (IQR): 3-5] and −1 (IQR: -2-1), respectively. The area under the ROC curve (AUC) was 0.922 [95% confidence interval (CI): 0.892-0.952; P < 0.001], indicating that the EGSYS score system has good discrimination. The best cutoff point was ≥3, with a sensitivity and specificity of 84.3% and 87.9%, respectively. The Hosmer-Lemeshow test demonstrated satisfactory calibration (χ²=1.468, P > 0.05) of the score, indicating a good fit of the model.

Conclusion

The EGSYS score appeared to be sensitive for differentiating CS from NMS in children. It might be used as an additional diagnostic tool to aid pediatricians in accurately identifying children with CS in the clinical practice.

[Evaluation of Disopyramide Efficacy for Refractory Syncope in Heart Failure with Preserved Ejection Fraction Using Holter Electrocardiography: A Case Report]

The management of syncope is clinically important for heart failure (HF) patients. We herein describe a case on the efficacy of disopyramide for refractory syncope in HF with preserved ejection fraction (HFpEF). An 82-year-old man was hospitalized for respiratory distress and lower limb edema and was subsequently diagnosed with HFpEF. The use of diuretics improved HF symptoms; however, on day 10 after hospitalization, a rapid decrease in blood pressure and transient loss of consciousness developed. After neurologic examination, he was diagnosed with pure autonomic failure. Although he was administered midodrine 8 mg/d, fludrocortisone 0.1 mg/d, and droxidopa 300 mg/d, syncope was observed once a day on average. According to the Holter electrocardiogram, the patient's heart rate and coefficient of variation of R-R intervals (CVRR) during the day were unstable. In addition, high frequency power (parasympathetic nerve activity) was significantly higher than low frequency power (both sympathetic and parasympathetic nerves activity), suggesting that the parasympathetic nerves may have been highly active while the sympathetic nerves would have been blocked. On day 29, a pharmacist proposed disopyramide 300 mg/d, which blocks parasympathetic nerves and improves neural-mediated syncope, to the attending doctor. After the initiation of disopyramide, transient loss of consciousness was not observed. Furthermore, the diurnal variation in the heart rate and CVRR completely disappeared. In conclusion, disopyramide would be effective for refractory syncope in patients with HFpEF, and the Holter electrocardiogram may be a useful tool for the assessment of drug efficacy by pharmacists.

Cardiac and Vascular Causes of Syncope and Atherosclerosis

PURPOSE OF REVIEW

Among the most common causes of cardiac syncope are arrhythmias and ischemic heart disease, both of which can coexist. The purpose of this review is to discuss the main causes of cardiac and vascular syncope related to atherosclerosis, its epidemiological and clinical aspects, warning signs, and initial approach.

RECENT FINDINGS

Cardiac syncope may have a frequency of up to 34% in elderly people. Atherosclerosis-related causes of cardiac and vascular syncope may be due to cardiac arrhythmia and/or structural impairment of the heart or arteries. Late ventricular tachycardia and late-onset high-grade atrioventricular block associated with myocardial ischemia may occur with syncope, which is related to higher mortality. Besides ventricular dysfunction, concentric remodeling is also a prognostic factor. In calcific degenerative aortic stenosis, syncope carries a worse prognosis than the other cardinal signs. Cardiac syncope has a high recurrence and mortality rate. There are red flag alerts that must be considered in risk stratification.

Syncope as the Initial Manifestation of Advanced Nasopharyngeal Carcinoma: A Case Report

Carotid sinus syndrome is a principal cause of syncope in the elderly. Syncope, associated with carotid sinus syndrome which is secondary to metastasis of advanced nasopharyngeal carcinoma, rarely occurs. The current study reported a 66-year-old woman, who presented with a history of frequent and recurrent syncope as the initial symptom, and was eventually diagnosed with advanced nasopharyngeal carcinoma. The positron emission tomography scan demonstrated a diagnosis of advanced nasopharyngeal carcinoma with involvement in carotid sheath space, and nasopharyngeal biopsy revealed non-keratinized nasopharyngeal carcinoma. After diagnosis and treatment, the patient had no recurrence of syncope. In summary, our case study suggests that great importance should be attached to potential intrinsic causes of syncope especially in the case of nasopharyngeal carcinoma, as it is an insidious malignancy which needs to be precisely identified.

Recent Updates and Technological Developments in Evaluating Cardiac Syncope in the Emergency Department

Syncope is a commonly encountered problem in the emergency department (ED), accounting for approximately 3% of presenting complaints. Clinical assessment of syncope can be challenging due to the diverse range of conditions that can precipitate the symptom. Annual mortality for patients presenting with syncope ranges from 0-12%, and if the syncope is secondary to a cardiac cause, then this figure rises to 18-33%. In ED, it is paramount to accurately identify those presenting with syncope, especially patients with an underlying cardiac aetiology, initiate appropriate management, and refer them for further investigations. In 2018, the European Society of Cardiology (ESC) updated its guidelines with regard to diagnosing and managing patients with syncope. We highlight recent developments and considerations in various components of the workup, such as history, physical examination, investigations, risk stratification, and novel biomarkers, since the establishment of the 2018 ESC guidelines. We further discuss the emerging role of artificial intelligence in diagnosing cardiac syncope and postulate how wearable technology may transform evaluating cardiac syncope in ED.

The ability of Canadian Syncope risk score in differentiating cardiogenic and non-cardiogenic syncope; a cross-sectional study

INTRODUCTION

Determining the underlying etiology of syncope provides valuable prognostic information and expedites the implementation of a therapeutic strategy. This study aimed to evaluate the ability of Canadian Syncope Risk Score (CSRS) in differentiating cardiogenic and non-cardiac syncope.

METHODS

The present diagnostic accuracy study was conducted on adult patients with syncope, who presented to the emergency departments of Shohadaye Tajrish and Imam Hossein Hospitals in Tehran from March 2018 to March 2019. The data required for determining CSRS were collected during the initial assessment and the underlying etiology was confirmed through further diagnostic follow-up under the supervision of a cardiologist or neurologist. Finally, the screening performance characteristics of the score were calculated.

RESULTS

300 patients with the mean age of 56.38 ± 19.10 years were studied. The source of syncope was cardiac in 133 (44.3%) and non-cardiac in 137 (55.7%) patients. The area under the ROC curve of CSRS in differentiating cardiac syncope was 0.77 (95% CI: 0.715-0.824). At a cutoff point of -1.5, the sensitivity and specificity of the score were calculated to be 73.68% (95% CI: 65.21-80.75%) and 73.05% (95%CI: 75.54-79.47%), respectively.

CONCLUSION

The present study reveals that CSRS has fair accuracy in differentiating the source of syncope and has no superiority over a clinical examination. Therefore, we do not recommend relying on the CSRS to differentiate between cardiac and non-cardiac syncope alone.

Developing and Demonstrating the Viability and Availability of the Multilevel Implementation Strategy for Syncope Optimal Care Through Engagement (MISSION) Syncope App: Evidence-Based Clinical Decision Support Tool

BACKGROUND

Syncope evaluation and management is associated with testing overuse and unnecessary hospitalizations. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Syncope Guideline aims to standardize clinical practice and reduce unnecessary services. The use of clinical decision support (CDS) tools offers the potential to successfully implement evidence-based clinical guidelines. However, CDS tools that provide an evidence-based differential diagnosis (DDx) of syncope at the point of care are currently lacking.

OBJECTIVE

With input from diverse health systems, we developed and demonstrated the viability of a mobile app, the Multilevel Implementation Strategy for Syncope optImal care thrOugh eNgagement (MISSION) Syncope, as a CDS tool for syncope diagnosis and prognosis.

METHODS

Development of the app had three main goals: (1) reliable generation of an accurate DDx, (2) incorporation of an evidence-based clinical risk tool for prognosis, and (3) user-based design and technical development. To generate a DDx that incorporated assessment recommendations, we reviewed guidelines and the literature to determine clinical assessment questions (variables) and likelihood ratios (LHRs) for each variable in predicting etiology. The creation and validation of the app diagnosis occurred through an iterative clinician review and application to actual clinical cases. The review of available risk score calculators focused on identifying an easily applied and valid evidence-based clinical risk stratification tool. The review and decision-making factors included characteristics of the original study, clinical variables, and validation studies. App design and development relied on user-centered design principles. We used observations of the emergency department workflow, storyboard demonstration, multiple mock review sessions, and beta-testing to optimize functionality and usability.

RESULTS

The MISSION Syncope app is consistent with guideline recommendations on evidence-based practice (EBP), and its user interface (UI) reflects steps in a real-world patient evaluation: assessment, DDx, risk stratification, and recommendations. The app provides flexible clinical decision making, while emphasizing a care continuum; it generates recommendations for diagnosis and prognosis based on user input. The DDx in the app is deemed a pragmatic model that more closely aligns with real-world clinical practice and was validated using actual clinical cases. The beta-testing of the app demonstrated well-accepted functionality and usability of this syncope CDS tool.

CONCLUSIONS

The MISSION Syncope app development integrated the current literature and clinical expertise to provide an evidence-based DDx, a prognosis using a validated scoring system, and recommendations based on clinical guidelines. This app demonstrates the importance of using research literature in the development of a CDS tool and applying clinical experience to fill the gaps in available research. It is essential for a successful app to be deliberate in pursuing a practical clinical model instead of striving for a perfect mathematical model, given available published evidence. This hybrid methodology can be applied to similar CDS tool development.

Multivariable risk scores for predicting short-term outcomes for emergency department patients with unexplained syncope: A systematic review

OBJECTIVES

Emergency department (ED) patients with unexplained syncope are at risk of experiencing an adverse event within 30 days. Our objective was to systematically review the accuracy of multivariate risk stratification scores for identifying adult syncope patients at high and low risk of an adverse event over the next 30 days.

METHODS

We conducted a systematic review of electronic databases (MEDLINE, Cochrane, Embase, and CINAHL) from database creation until May 2020. We sought studies evaluating prediction scores of adults presenting to an ED with syncope. We included studies that followed patients for up to 30 days to identify adverse events such as death, myocardial infarction, stroke, or cardiac surgery. We only included studies with a blinded comparison between baseline clinical features and adverse events. We calculated likelihood ratios and confidence intervals (CIs).

RESULTS

We screened 13,788 abstracts. We included 17 studies evaluating nine risk stratification scores on 24,234 patient visits, where 7.5% (95% CI = 5.3% to 10%) experienced an adverse event. A Canadian Syncope Risk Score (CSRS) of 4 or more was associated with a high likelihood of an adverse event (LR_score≥4  = 11, 95% CI = 8.9 to 14). A CSRS of 0 or less (LR_score≤0  = 0.10, 95% CI = 0.07 to 0.20) was associated with a low likelihood of an adverse event. Other risk scores were not validated on an independent sample, had low positive likelihood ratios for identifying patients at high risk, or had high negative likelihood ratios for identifying patients at low risk.

CONCLUSION

Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known.

ACR Appropriateness Criteria® Syncope

Syncope and presyncope lead to well over one million emergency room visits in the United States each year. Elucidating the cause of syncope or presyncope, which are grouped together given similar etiologies and outcomes, can be exceedingly difficult given the diverse etiologies. This becomes more challenging as some causes, such as vasovagal syncope, are relatively innocuous while others, such as cardiac-related syncope, carry a significant increased risk of death. While the mainstay of syncope and presyncope assessment is a detailed history and physical examination, imaging can play a role in certain situations. In patients where a cardiovascular etiology is suspected based on the appropriate history, physical examination, and ECG findings, resting transthoracic echocardiography is usually considered appropriate for the initial imaging. While no imaging studies are considered usually appropriate when there is a low probability of cardiac or neurologic pathology, chest radiography may be appropriate in certain clinical situations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Syncope in the Emergency Department: A Guide for Clinicians

Syncope is a common presenting symptom to emergency departments, but its evaluation and initial management can be challenging for ED practitioners and particularly urgent in the presence of high-risk features that increase the likelihood of cardiac etiology. Even after thorough clinical evaluation, syncope may remain unexplained. In such instances, practitioners' clinical judgment and risk assessments are critical to guide further management. In this article, evidence-informed strategies are outlined to approach the diagnosis of syncope and provide an overview of syncope clinical decision rules and shared decision-making. By incorporating risk stratification and shared decision-making into syncope care, practitioners can more confidently engage patients and families in disposition decisions to organize appropriate outpatient and follow-up care, observation, or admission.

Cardiogenic vertigo: characteristics and proposed diagnostic criteria

Early identification of cardiogenic vertigo (CV) is necessary to prevent serious complications of cardiovascular diseases. However, the literature is limited to case reports without detailed clinical features or diagnostic criteria. The aim of this study was to define characteristics of CV and propose diagnostic criteria. This study included patients with CV diagnosed at Pusan National University and Keimyung University Hospitals. Demographic, clinical, laboratory, and treatment data were analyzed. Of 72 patients with clinically suspicious CV, 27 were finally included. The age ranged from 63 to 88 years (75.1 ± 7.2 years). Recurrent vertigo occurred without syncopal attacks in 52% [95% CI, 32-71], while it preceded (37% [19-58]) or followed (11% [2-29]) syncope. The patients with recurrent isolated vertigo had suffered from symptoms from 15 days to 5 years until final diagnosis (median 122 days). The vertigo lasted only for a few seconds (93% [76-99]) or a few minutes (7% [1-24]). Fourteen patients presented with spinning vertigo, and one of them showed spontaneous downbeat nystagmus during the attack. Accompanying symptoms including chest discomfort, palpitation, headache, arm twitching, and lightheadedness were found in 70% [50-86]. Between patients with and without syncope, there was no difference in clinical parameters and results of cardiac function tests. The most common cardiac abnormality during the attacks of vertigo was bradyarrhythmia (89% [71-98]). Cardiovascular diseases can develop recurrent isolated vertigo without or preceding syncope. Onset age, duration of vertigo, accompanying symptoms, and underlying cardiac diseases can aid in differentiation from other vestibular disorders. Early identification of CV would reduce morbidity and mortality associated with cardiac syncope.

Contemporary management of patients with syncope in clinical practice: an EHRA physician-based survey

Syncope is a heterogeneous syndrome encompassing a large spectrum of mechanisms and outcomes. The European Society of Cardiology published an update of the Syncope Guidelines in 2018. The aim of the present survey was to capture contemporary management of syncope and guideline implementation among European physicians. A 23-item questionnaire was presented to 2588 European Heart Rhythm Association (EHRA) members from 32 European countries. The response rate was 48%, but only complete responses (n = 161) were included in this study. The questionnaire contained specific items regarding syncope facilities, diagnostic definitions, diagnostic tools, follow-up, and therapy. The survey revealed that many respondents did not have syncope units (88%) or dedicated management algorithms (44%) at their institutions, and 45% of the respondents reported syncope-related hospitalization rates >25%, whereas most (95%) employed close monitoring and hospitalization in syncope patients with structural heart disease. Carotid sinus massage, autonomic testing, and tilt-table testing were inconsistently used. Indications were heterogeneous for implanted loop recorders (79% considered them for recurrent syncope in high-risk patients) or electrophysiological studies (67% considered them in bifascicular block and inconclusive non-invasive testing). Non-pharmacological therapy was consistently considered by 68% of respondents; however, there was important variation regarding the choice of drug and device therapy. While revealing an increased awareness of syncope and good practice, our study identified important unmet needs regarding the optimal management of syncope and variable syncope guideline implementation.