Evaluation and outcome of emergency room patients with transient loss of consciousness

Management of Patients With Unexplained Syncope: Derivation and Validation of a Simplified 2-Step Diagnostic Approach

BACKGROUND

The aim of this study was to develop a structured 2-step approach, based on noninvasive diagnostic criteria, that led to an electrophysiology study in patients with unexplained syncope.

METHODS AND RESULTS

Two independent cohorts were used: the derivation cohort with 665 patients based on electronic health record data to develop our 2-step diagnostic approach, and the validation cohort based on 160 prospectively screened patients, presenting with unexplained syncope episodes. Noninvasive electrocardiographic and imaging markers and an electrophysiology study-based invasive assessment were combined. A positive diagnostic approach according to our study's prespecified criteria resulted in a decision to proceed with a permanent pacemaker/implantable cardioverter-defibrillator. The primary end point was the time until the event of recurrent syncope (syncope-free survival). Number needed to treat was calculated for patients with a positive diagnostic approach. The number of patients with unexplained syncope and borderline sinus bradycardia needed to treat was 5, and the number of patients with unexplained syncope and bundle branch block needed to treat was 3 over a mean follow-up of ≈4 years. After the structured 2-step approach, the primary outcome occurred in 14 of 82 (17.1%) with a pacemaker/implantable cardioverter-defibrillator and 19 of 57 (33%) with a negative approach, with a mean follow-up of ≈2.5 years (29.29±12.58 months, P=0.03).

CONCLUSIONS

The low number needed to treat in the derivation cohort and the low percentage of syncope recurrence in the validation cohort supports the proposed 2-step electrophysiology-inclusive algorithm as a potentially low-cost, 1-day, structured tool for these patients.

Implementation of the Canadian syncope pathway: a pilot non-randomized stepped wedge trial

BACKGROUND

We developed the Canadian Syncope Pathway (CSP) based on the Canadian Syncope Risk Score (CSRS) to aid emergency department (ED) syncope management. This pilot implementation study assessed patient inclusion, length of transition period, as well as process measures (engagement, reach, adoption, and fidelity) to prepare for multicenter implementation.

METHODS

A non-randomized stepped wedge trial at two hospitals was conducted over a 7-month period. After 2-3 months in the control condition, the hospitals crossed over in a stepwise fashion to the intervention condition. Study participants were ED and non-ED physicians, or their delegates, and patients (aged ≥ 18 years) with syncope. We aimed to analyze patient characteristics, ED management including disposition decision, and CSRS recommendations application for all eligible patients during the intervention period. Our targets were 95% inclusion rate, 70% adoption (proportion of physicians who applied the pathway), 60% reach (intervention applied to eligible patients) and 70% fidelity (appropriate recommendations application) for all eligible patients. Clinical Trials registration NCT04790058.

RESULTS

1002 eligible patients (mean age 56.6 years; 51.0% males) were included: 349 patients during the control and 653 patients during the intervention period. Physician engagement varied from 39.7% to 97.1% for presentation at meetings. Process measures for the first month and the end of the intervention were: adoption 70.7% (58/82) and 84.4% (103/122), reach 67.5% (108/160) and 55.0% (359/653), fidelity among patients with physician data form completion 86.3% (88/102) and 88.3% (294/333), versus fidelity among all eligible patients 83.8% (134/160) and 83.3% (544/653) respectively with no significant differences in fidelity at one month and the end of the intervention period.

CONCLUSION

In this pilot study, we achieved all prespecified benchmarks for proceeding to the multicenter CSP implementation except reach. Our results indicate a 1-month transition period will be adequate though regular reminders will be needed during full-scale implementation.

Adenosinergic System and Neuroendocrine Syncope: What Is the Link?

Although very common, the precise mechanisms that explain the symptomatology of neuroendocrine syncope (NES) remain poorly understood. This disease, which can be very incapacitating, manifests itself as a drop in blood pressure secondary to vasodilation and/or extreme slowing of heart rate. As studies continue, the involvement of the adenosinergic system is becoming increasingly evident. Adenosine, which is an ATP derivative, may be involved in a large number of cases. Adenosine acts on G protein-coupled receptors with seven transmembrane domains. A1 and A2A adenosine receptor dysfunction seem to be particularly implicated since the activation leads to severe bradycardia or vasodilation, respectively, two cardinal symptoms of NES. This mini-review aims to shed light on the links between dysfunction of the adenosinergic system and NHS. In particular, signal transduction pathways through the modulation of cAMP production and ion channels in relation to effects on the cardiovascular system are addressed. A better understanding of these mechanisms could guide the pharmacological development of new therapeutic approaches.

Association between Syncope and the 6-Month Incidence of Ischemic Stroke, Arrhythmia, Brain Tumor, Epilepsy, and Anxiety Disorder

OBJECTIVES

the aim of the present study is to investigate the associations between syncope and subsequent diagnoses of brain tumor, cardiac arrhythmia, stroke/transient ischemic attack (TIA), epilepsy, and anxiety disorder in a large outpatient population in Germany.

METHODS

This retrospective cohort study uses data from the Disease Analyzer database (IQVIA). Adults who received syncope diagnosis from one of 1284 general practices between January 2005 and December 2021 (index date) were included and matched (1:1) to individuals without syncope diagnosis using a propensity score based on age, sex, the number of consultations during the follow-up period (up to 6 months), and defined co-diagnoses documented within 12 months prior to and on the index date. Finally, associations between syncope and subsequent outcome diagnoses were investigated using multivariable logistic regression models.

RESULTS

Data related to 64,016 patients with and 64,016 patients without syncope (mean age 54.5 years, 56.5% female) were available. In total, 6.43% of syncope patients and 2.14% of non-syncope patients were diagnosed with one of the five outcome diagnoses within 6 months of the index date. There was a positive and significant association between syncope and incidences of ischemic stroke/TIA (OR = 2.83, 95% CI = 2.41-3.32), arrhythmia (OR = 3.81, 95% CI = 3.44-4.18), brain tumor (OR = 4.24, 95% CI = 2.50-7.19), epilepsy (OR = 5.52, 95% CI = 4.27-7.14), and anxiety disorder (OR = 1.99, 95% CI = 1.79-2.21).

CONCLUSIONS

Syncope is significantly associated with an increased risk of subsequent ischemic stroke/TIA, cardiac arrhythmia, brain tumor, epilepsy, and anxiety disorder. Nevertheless, the cumulative incidences for all five diagnoses are very low.

An Unexpected Cause of Syncope

Syncope is a common chief complaint among patients presenting to the emergency department, the etiology of which can often be discerned with a thorough history and physical examination. Inversely, liposarcomas are rare tumors that frequently pose a diagnostic challenge as the clinical presentation is highly nonspecific and varies greatly depending on the anatomic location and size of the tumor. Here we present a case of retroperitoneal liposarcomas (RLS) presenting to the emergency department (ED) with a sole complaint of syncope, resulting in a diagnostic dilemma. This clinical scenario highlights the significance of thorough physical examination regardless of the presenting chief complaint, as unexpected physical examination findings prompted an extended work-up and thus facilitated the diagnosis, providing the opportunity for early intervention and resection of the tumor.

Classic Presentation of Catecholaminergic Polymorphic Ventricular Tachycardia: A Case Report

Syncope is a common reason for children and adolescents to seek care in the emergency department. Often syncopal episodes are benign and most commonly due to a vasovagal event. Occasionally an underlying cardiac arrhythmia is responsible. We present a case report of a 17-year-old male who collapsed during an emotional event and went into cardiac arrest. Emergency department evaluation including imaging, laboratory studies, and EKG indicated the cause of cardiac arrest was likely a primary cardiac arrhythmia. An initial clinical diagnosis of catecholaminergic polymorphic ventricular tachycardia (CPVT) was made based on symptom onset during an emotional event, family history of sudden cardiac death, patient age, past episodes of chest pain and palpitations, absence of structural heart defect, and lack of EKG changes after the return of spontaneous circulation (ROSC). The diagnosis was later confirmed with genetic testing. The patient was started on a beta-blocker and a subcutaneous implantable cardioverter-defibrillator (S-ICD, Boston Scientific, Marlborough, MA) was placed. Given the rarity of this condition, this diagnosis is often missed, which contributes to increased mortality rates. In children and young adults presenting with syncope without clear etiology in the presence of high-risk features, further evaluation should be performed including referral to cardiology to rule out chronic cardiac arrhythmias.

Adenosine, Adenosine Receptors and Neurohumoral Syncope: From Molecular Basis to Personalized Treatment

Adenosine is a ubiquitous nucleoside that is implicated in the occurrence of clinical manifestations of neuro-humoral syncope (NHS). NHS is characterized by a drop in blood pressure due to vasodepression together with cardio inhibition. These manifestations are often preceded by prodromes such as headaches, abdominal pain, feeling of discomfort or sweating. There is evidence that adenosine is implicated in NHS. Adenosine acts via four subtypes of receptors, named A1 (A1R), A2A (A2AR), A2B (A2BR) and A3 (A3R) receptors, with all subtypes belonging to G protein membrane receptors. The main effects of adenosine on the cardiovascular system occurs via the modulation of potassium ion channels (IK Ado, K ATP), voltage-gate calcium channels and via cAMP production inhibition (A1R and A3R) or, conversely, through the increased production of cAMP (A2A/BR) in target cells. However, it turns out that adenosine, via the activation of A1R, leads to bradycardia, sinus arrest or atrioventricular block, while the activation of A2AR leads to vasodilation; these same manifestations are found during episodes of syncope. The use of adenosine receptor antagonists, such as theophylline or caffeine, should be useful in the treatment of some forms of NHS. The aim of this review was to summarize the main data regarding the link between the adenosinergic system and NHS and the possible consequences on NHS treatment by means of adenosine receptor antagonists.

Permanent pacemaker implantation in unexplained syncope patients with electrophysiology study-proven atrioventricular node disease

BACKGROUND

Syncope, whose cause is unknown after an initial assessment, has an uncertain prognosis. It is critical to identify patients at highest risk who may require a pacemaker and to identify the cause of recurrent syncope to prescribe proper therapy. Aim of this study was to evaluate the effect of permanent pacing on the incidence of syncope in patients with unexplained syncope and electrophysiology study-proven atrioventricular node disease.

MATERIAL AND METHODS

This was an observational study based on a prospective registry of 236 consecutive patients (60.20 ± 18.66 years, 63.1% male, 60.04 ± 9.50 bpm) presenting with recurrent unexplained syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). The decision to implant a permanent pacemaker was made in all cases by the attending physicians according to the results of the EPS. 135 patients received the antibradycardia pacemaker (ABP), while 101 declined.

RESULTS

The mean of reported syncope episodes was 1.97 ± 1.10 (or presyncope 2.17 ± 1.50) before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (49.19 ± 29.58 months), the primary outcome event (syncope) occurred in 31 of 236 patients (13.1%), 6 of 135 (4.4%) in the ABP group as compared to 25 of 101 (24.8%) in the no pacemaker group (p < 0.001).

CONCLUSION

Among patients with a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined atrioventricular node disease, identifies a subset of patients who will benefit from permanent pacing.

Clinical utility of serum prolactin and lactate concentrations to differentiate epileptic seizures from non-epileptic attacks in the emergency room

PURPOSE

To evaluate the diagnostic utility of serum prolactin (PRL) and lactate (LAC) concentrations for patients presenting with either or both convulsions and transient loss of consciousness (TLOC) in the emergency room (ER).

METHODS

This was a retrospective single-center study conducted in a tertiary care hospital ER. Medical records of consecutive patients who presented with convulsions or TLOC between January 2018 and December 2020 were reviewed. Patients with an ER diagnosis of epileptic seizures, psychogenic non-epileptic seizure (PNES), and syncope were selected for analysis. Serum PRL and LAC concentrations were measured within 3 h of the event and compared between groups.

RESULTS

Among the 440 eligible patients, 173 (39.3%) were included for analysis. Serum PRL concentration was significantly higher in patients with epileptic seizures with convulsions than in those with PNES with convulsions (p < 0.001) and convulsive syncope (p = 0.023). Serum LAC concentration was not significantly elevated in patients with convulsive syncope. Using a PRL cut-off value of 24.0 ng/mL, serum PRL concentration had 100.0% sensitivity and 82.9% specificity for differentiating between PNES and other attacks without convulsions.

CONCLUSION

Elevated serum PRL with normal serum LAC concentration in patients who have attacks with convulsions suggests convulsive syncope. Serum PRL concentration is useful in the diagnosis of PNES with convulsions. However, serum LAC concentration is not useful as a routine screening test for attacks without convulsions in the ER.

Unexplained Syncope: The Importance of the Electrophysiology Study

Syncope of cardiac origin may be associated with an increased risk of sudden cardiac death if not treated in a timely and appropriate manner. The diagnostic approach of syncope imposes a significant economic burden on society. The investigation and elucidation of the pathogenetic mechanism of syncope are of great clinical importance, as both prognosis and appropriate therapeutic approaches depend on these factors. The responsible mechanism of presyncope or syncope can only be revealed through the patient history, baseline clinical examination and electrocardiogram. The percentage of patients who are diagnosed with these tests alone exceeds 50%. In patients with a history of organic or acquired heart disease or/and the presence of abnormal findings on the electrocardiogram, a further diagnostic electrophysiology inclusive approach should be followed to exclude life threatening arrhythmiological mechanism. However, if the patient does not suffer from underlying heart disease and does not show abnormal electrocardiographic findings in the electrocardiogram, then the probability in the electrophysiology study to find a responsible cause is small but not absent. The role of a two-step electrophysiology study inclusive risk stratification approach for the effective management of the former is thoroughly discussed in this review.

Syncope, Epilepsy and Ictal Asystole: A Case Series and Narrative Review

IMPORTANCE

Syncope is a common presentation to emergency departments, and cardiac and neurological aetiologies are the predominant causes. Ictal asystole is a rare cardio-neural phenomenon seen in epilepsy syndromes whereby a seizure causes asystole (≥3 s) leading to syncope.

OBSERVATIONS

We present three cases of ictal asystole, together with a narrative review of the literature to assess the prevalence of the condition and review the pathophysiology, diagnosis and management. Our review of the literature has shown that ictal asystole is an unlikely contributor to sudden unexplained death with epilepsy (SUDEP). Pacemaker insertion may limit morbidity from trauma related to syncopal episodes but does not impact mortality.

CONCLUSIONS AND RELEVANCE

Patients with ictal asystole should be diagnosed with concurrent electroencephalogram-electrocardiograph (EEG-ECG) monitoring, have their anti-epileptic drugs optimised and be considered for epilepsy surgery if feasible. The use of longer term ECG monitoring may be used as a diagnostic aid if ictal asystole is suspected. If there are ongoing syncopal episodes with associated ictal asystole ≥6 seconds, particularly despite medical therapy, a permanent pacemaker may be considered to reduce morbidity. Current guidelines should be updated to reflect the increasing knowledge of this condition.

The Impact of Relational and Organizational-Environmental Aspects in Hospital Blood Collection: Clinical and Health Indications and New Training Needs

This study deals with people who underwent a blood test and consequently suffered a fainting episode in the past. This phenomenon affects many people and if not adequately dealt with, it can lead to a perception of the blood test as a serious and traumatic event, which could limit its use as a preventive diagnostic tool. These experiences have been explored by research mainly on the basis of the physiological mechanisms involved in fainting, with a few studies considering the actual lived experience related to the blood test. This study explored how this experience is lived and managed, capturing aspects that could facilitate blood tests and the procedures associated with them, thus it focused on people with vasovagal syncope and was articulated through the semi-structured interview methodology. Among the significant results is the importance of the relational aspects implemented by health staff, the differing organisation of the blood test procedure, the need to make the hospital environment less aseptic and more humanistic, effective actions to counter the anxieties relating to the administration of the blood test and the importance of including the blood test with an inter-disciplinarity perspective.

Permanent pacemaker implantation in unexplained syncope patients with borderline sinus bradycardia and electrophysiology study-proven sinus node disease

BACKGROUND

Significant sinus bradycardia (SB) in the context of sinus node dysfunction (SND) has been associated with neurological symptoms. The objective was to evaluate the effect of permanent pacing on the incidence of syncope in patients with rather mild degrees of SB, unexplained syncope, and "positive" invasive electrophysiologic testing.

METHODS

This was an observational study based on a prospective registry of 122 consecutive mild SB patients (61.90 ± 18.28 years, 61.5% male, 57.88 ± 7.73 bpm) presenting with recurrent unexplained pre and syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). Τhe implantation of a permanent antibradycardia pacemaker (ABP) was offered to all patients according to the results of the EPS. Eighty patients received the ABP, while 42 denied.

RESULTS

The mean of reported syncope episodes was 2.23 ± 1.29 (or presyncope 2.36 ± 1.20) in the last 12 months before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (50.39 ± 32.40 months), the primary outcome event (syncope) occurred in 18 of 122 patients (14.8%), 6 of 80 (7.5%) in the ABP group as compared to 12 of 42 (28.6%) in the no pacemaker group (P = .002).

CONCLUSIONS

Among patients with mild degree of SB and a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined SND after differentiating reflex syncope, identifies a subset of patients who will benefit from permanent pacing.

Association Between US Physician Malpractice Claims Rates and Hospital Admission Rates Among Patients With Lower-Risk Syncope

IMPORTANCE

The US Government Accountability Office has changed its estimate of the annual costs of defensive medicine, largely because it has been difficult to objectively measure its impact. Evaluating the association of malpractice claims rates with hospital admission rates and the costs of admitting patients with low-risk conditions would help to document the impact of defensive medicine. Although syncope is a concerning symptom, most patients with syncope have a low risk of adverse outcomes. However, many low-risk patients are still admitted to the hospital, with associated costs of more than $2.5 billion per year in the US.

OBJECTIVE

To assess whether hospital admission rates after emergency department visits among patients with lower-risk syncope are associated with state-level variations in malpractice claims rates.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of emergency department visits among patients with lower-risk syncope used deidentified data from the Clinformatics Data Mart database (Optum). Lower-risk syncope visits were defined as those with a primary diagnosis of syncope and collapse based on International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 or International Classification of Diseases, Tenth Revision, Clinical Modification code R55 that did not include another major diagnostic code for a condition requiring hospital admission (such as heart disease, cancer, or medical shock) or an inpatient hospital stay of more than 3 days. These data were linked to publicly available data from the National Practitioner Data Bank pertaining to physician malpractice claims between January 1, 2008, and December 31, 2017. The 2 data sets were linked at the state-year level. Data were analyzed from October 2, 2019, to September 12, 2020.

MAIN OUTCOMES AND MEASURES

The association between the rate of hospital admission after emergency department visits among patients with lower-risk syncope and the rate of physician malpractice claims was assessed at the state-year level using a state-level fixed-effects model. Standardized costs obtained from the Clinformatics Data Mart database were adjusted for inflation and expressed in 2017 US dollars using the Consumer Price Index.

RESULTS

Among 40 482 813 emergency department visits between 2008 and 2017, 519 724 visits (1.3%) were associated with syncope. Of those, 234 750 visits (45.2%) met the criteria for lower-risk syncope. The mean (SD) age of patients in the lower-risk cohort was 71.8 (13.5) years; 141 050 patients (60.1%) were female, and 44 115 patients (18.8%) were admitted to the hospital, representing an extra cost of $6542 per admission. The mean rate of physician malpractice claims varied from 0.27 claims per 100 000 people to 8.63 claims per 100 000 people across states and across years within states. A state-level fixed-effects regression model indicated that, for every 1 in 100 000-person increase in the physician malpractice claims rate, there was an absolute increase of 6.70% (95% CI, 4.65%-8.75%) or a relative increase of 35.6% in the hospital admission rate, which represented an additional $102 million in costs associated with this lower-risk cohort.

CONCLUSIONS AND RELEVANCE

In this study, increases in physician malpractice claims rates were associated with increases in hospital admission rates and substantial health care costs for patients with lower-risk syncope, and these increases are likely associated with the practice of defensive medicine.

Adenosine and the Cardiovascular System: The Good and the Bad

Adenosine is a nucleoside that impacts the cardiovascular system via the activation of its membrane receptors, named A₁R, A_2AR, A_2BR and A₃R. Adenosine is released during hypoxia, ischemia, beta-adrenergic stimulation or inflammation and impacts heart rhythm and produces strong vasodilation in the systemic, coronary or pulmonary vascular system. This review summarizes the main role of adenosine on the cardiovascular system in several diseases and conditions. Adenosine release participates directly in the pathophysiology of atrial fibrillation and neurohumoral syncope. Adenosine has a key role in the adaptive response in pulmonary hypertension and heart failure, with the most relevant effects being slowing of heart rhythm, coronary vasodilation and decreasing blood pressure. In other conditions, such as altitude or apnea-induced hypoxia, obstructive sleep apnea, or systemic hypertension, the adenosinergic system activation appears in a context of an adaptive response. Due to its short half-life, adenosine allows very rapid adaptation of the cardiovascular system. Finally, the effects of adenosine on the cardiovascular system are sometimes beneficial and other times harmful. Future research should aim to develop modulating agents of adenosine receptors to slow down or conversely amplify the adenosinergic response according to the occurrence of different pathologic conditions.

EGSYS score for the prediction of cardiac etiology in syncope: Is it useful in an outpatient setting?

INTRODUCTION

The EGSYS score uses clinical variables to predict which patients may have cardiac (CS) or non-cardiac syncope (NCS) and has been validated in the emergency department setting. This study aims to determine whether the score has the same applicability in an outpatient setting.

METHODS

In this retrospective study of all patients observed in the outpatient setting of a hospital with a syncope unit between January 2015 and December 2016, the EGSYS score was calculated for each patient, and its sensitivity and specificity were determined for the prediction of CS in patients with score ≥3.

RESULTS

A total of 224 patients, mean age 64.3±21.7 years, 116 (51.8%) male, were analyzed. In the 163 (72.7%) patients with confirmed syncope, CS was diagnosed in 27 (16.6%) and NCS in 136 (83.4%). The EGSYS score was ≥3 in 40 (20.0%) patients with NCS and in 13 (48.1%) with CS. A positive score had a sensitivity of 48.2% (95% CI: 28.7-68.1), a specificity of 77.9% (95% CI: 70.0-84.6), and a positive and negative predictive value of 30.2% (95% CI: 20.8-41.8) and 88.3% (95% CI: 83.9-91.7), respectively.

CONCLUSION

The EGSYS score has limited usefulness in an outpatient setting, where observed patients have already been been medically assessed. Given its high specificity and negative predictive value, it may be useful to reassure low-risk patients and family members.

Diagnostic yield of pulmonary embolism testing in patients presenting to the emergency department with syncope

BACKGROUND

Syncope occurs in 1 in 4 people during their lifetime and accounts for 1% to 1.5% of emergency department (ED) visits. Most causes of syncope are benign, but syncope may be caused by life-threatening conditions including pulmonary embolism (PE) in up to 2% of cases. A recent publication reported the prevalence of PE in patients with syncope to be over 17%.

AIMS

We sought to determine the frequency and diagnostic yield of testing for PE in patients presenting to the ED with syncope in our large, integrated health care system.

METHODS

We performed a retrospective, longitudinal cohort study of patients who presented with syncope to EDs within a 21-hospital integrated health care system from 2010 to 2015 to find the frequency and diagnostic yield of testing for PE in patients with syncope at index ED visit and within 180 days afterward.

RESULTS

We screened 2 749 371 ED encounters to find 32 440 (1.2%) with syncope. Median age was 52 (interquartile range, 31-71), 57.5% were female, and 90% were Caucasian. PE was diagnosed on the index ED visit in 259 (0.8%; 95% confidence interval [CI], 0.7%-0.9%) cases. Assessment for suspected PE with D-dimer occurred in 5089 (15.7%) patients, and 2338 (7.2%) underwent computed tomography pulmonary angiography (CTPA). The yield of CTPA was 7.9%. PE was detected in 2.2% in whom a D-dimer was performed. From index visit to 180 days, 467 (1.4%; 95% CI, 1.3%-1.6%) patients were diagnosed with a PE, and 1051 (3.2%, 95% CI, 3.0%-3.4%) patients died.

CONCLUSION

Diagnostic testing for PE is frequent in patients with syncope presenting to the EDs of a large, integrated health care system. The yield of diagnostic testing is low.

Role of baseline 12‑lead ECG in predicting syncope caused by arrhythmia in patients investigated using an implantable loop recorder

AIM

To evaluate the role of baseline 12‑lead ECG in predicting the syncope mechanism during continuous monitoring using an implantable loop recorder (ILR).

METHODS

Consecutive patients with syncope implanted with an ILR were enrolled. Baseline 12‑lead ECG were related to ECG diagnosis derived from ILR tracings recorded at the time of syncope recurrence.

RESULTS

In total 300 patients with a mean age of 66 ± 16 years were included, 49% (146/300) received an ILR-guided diagnosis during follow-up. Patients with abnormal baseline ECG more frequently received an ILR-guided diagnosis compared to those with normal baseline ECG 59% vs. 44%, p = 0.018. For a diagnosis of arrhythmic syncope, the corresponding frequencies were 45% vs. 26%, p = 0.001.Patients with bifascicular block significantly more common received an ILR-guided diagnosis 76% (25/33) compared to those with normal baseline ECG 44% (90/205), p ≪ 0.001. In this subgroup, 96% (24/25) were diagnosed with arrhythmic syncope, 23 of which were due to bradyarrhythmia. Bifascicular block occurred almost exclusively among those ≥60 years (31/33). After logistic regression the adjusted OR for arrhythmic syncope was significant for bifascicular block 5.5 (95%CI 2.3-13.2), p ≪ 0.001. PPV for bifascicular block in predicting arrhythmic syncope was 73% and NPV 73%.

CONCLUSION

A baseline 12‑lead ECG with bifascicular block was a strong predictor for syncope during follow-up, most often due to bradyarrhythmia caused by intermittent complete heart block. No other ECG findings were associated with the ILR outcome. We find it reasonable to consider permanent pacing instead of an ILR for patients with bifascicular block and unexplained syncope.

Diagnostic Performance of the Electroencephalogram in the Elderly Manifesting With Episodes of Unresponsiveness

This study aimed to determine diagnostic performance of the EEG in diagnosing seizures and to ascertain risk factors associated with seizures in the elderly presenting with episodes of unresponsiveness compared with younger patients. This is a cross-sectional study. Only EEGs requested with indication of transient unresponsiveness (TUR) were included. Patients were divided into 2 groups, younger (aged 18-49 years) and elderly (aged >60 years). The EEG was an index test. Reference standard, independently verified by 2 board-certified neurologists, was a clinical diagnosis of presence or absence of epilepsy/probable seizures. Univariate and multivariate analyses were performed to ascertain associated risk factors for epilepsy/probable seizures. Among 2187 total EEG recordings, 244 (11.16%) recordings were requested with indication of TUR. A total of 156 patients (50 younger and 106 elderly) were recruited for analysis. Prevalence of epilepsy/probable seizures in patients with TUR was 26.9%. Prevalence of interictal epileptiform discharges was 16% in the younger and 12.3% in the elderly. Overall diagnostic performance was poorer in the elderly. Associated risk factors for having seizures were presence of intermittent slow waves in the younger and presence of positive motor signs as well as presence of nonepileptiform abnormalities in the elderly. Prevalence of seizures and interictal epileptiform discharges was low in the elderly who manifests with TUR. Overall diagnostic performance of the EEG in diagnosing seizures was poorer in the elderly mainly due to low sensitivity. When we encounter patients with TUR, thorough and detailed history is still a mainstay of a diagnosis of seizures, not the EEG results.

The Yield of Computed Tomography of the Head Among Patients Presenting With Syncope: A Systematic Review

BACKGROUND

Overuse of head computed tomography (CT) for syncope has been reported. However, there is no literature synthesis on this overuse. We undertook a systematic review to determine the use and yield of head CT and risk factors for serious intracranial conditions among syncope patients.

METHODS

We searched Embase, Medline, and Cochrane databases from inception until June 2017. Studies including adult syncope patients with part or all of patients undergoing CT head were included. We excluded case reports, reviews, letters, and pediatric studies. Two independent reviewers screened the articles and collected data on CT head use, diagnostic yield (proportion with acute hemorrhage, tumors or infarct), and risk of bias. We report pooled percentages, I² , and Cochran's Q-test.

RESULTS

Seventeen articles with 3,361 syncope patients were included. In eight ED studies (n = 1,669), 54.4% (95% confidence interval [CI] = 34.9%-73.2%) received head CT with a 3.8% (95% CI = 2.6%-5.1%) diagnostic yield and considerable heterogeneity. In six in-hospital studies (n = 1,289), 44.8% (95% CI = 26.4%-64.1%) received head CT with a 1.2% (95% CI = 0.5%-2.2%) yield and no heterogeneity. In two articles, all patients had CT (yield 2.3%) and the third enrolled patients ≥ 65 years old (yield 7.7%). Abnormal neurologic findings, age ≥ 65 years, trauma, warfarin use, and seizure/stroke history were identified as risk factors. The quality of all articles referenced was strong.

CONCLUSION

More than half of patients with syncope underwent CT head with a diagnostic yield of 1.1% to 3.8%. A future large prospective study is needed to develop a robust risk tool.

The value of multidisciplinary team in syncope clinic for the effective diagnosis of complex syncope

BACKGROUND

Syncope is a perplexing challenge that often receives thorough evaluation, yet the diagnosis remains unclear. Usually, the emergency department is the first point at which patients present with syncope. However, diverse medical factors, including low diagnostic rates and inconsistent management by doctors, add to healthcare costs and delay diagnosis for syncope patients.

METHODS

Patients who had been to the emergency department at least once but were not given a clear diagnosis of syncope were recruited into our study at the time they visited syncope clinic staffed by a multidisciplinary team. Complete medical histories and clinical examinations were conducted by both experienced cardiologists and neurologists. If patients were not given a conclusive diagnosis at the syncope clinic on the basis of outpatient examinations, they were admitted for further evaluation.

RESULTS

A total of 209 consecutive patients claiming "syncope" visited the syncope clinic, yet only 167 patients were formally diagnosed with syncope. For these 167 patients, the mean age was 55.93 ± 17.40 years old, and 41.3% were male. The proportions of cardiac syncope, reflex syncope, orthostatic hypotension (OH), and syncope of uncertain etiology were 19.8%, 64.1%, 7.8%, and 8.4%, respectively. The diagnostic rate was 91.6%, and the hospitalization rate was 23.4%. Patients with reflex syncope and OH were younger than patients with cardiac syncope. Cardiac syncope tends to occur more frequently in males, while reflex syncope is more likely in females.

CONCLUSIONS

The cooperation of professional cardiologists and neurologists will play an important role in improving diagnostic rates, lowering admission rates, and reducing medical costs.

Using the Boston Syncope Observation Management Pathway to Reduce Hospital Admission and Adverse Outcomes

Introduction

In an age of increasing scrutiny of each hospital admission, emergency department (ED) observation has been identified as a low-cost alternative. Prior studies have shown admission rates for syncope in the United States to be as high as 70%. However, the safety and utility of substituting ED observation unit (EDOU) syncope management has not been well studied. The objective of this study was to evaluate the safety of EDOU for the management of patients presenting to the ED with syncope and its efficacy in reducing hospital admissions.

Methods

This was a prospective before-and-after cohort study of consecutive patients presenting with syncope who were seen in an urban ED and were either admitted to the hospital, discharged, or placed in the EDOU. We first performed an observation study of syncope management and then implemented an ED observation-based management pathway. We identified critical interventions and 30-day outcomes. We compared proportions of admissions and adverse events rates with a chi-squared or Fisher’s exact test.

Results

In the “before” phase, 570 patients were enrolled, with 334 (59%) admitted and 27 (5%) placed in the EDOU; 3% of patients discharged from the ED had critical interventions within 30 days and 10% returned. After the management pathway was introduced, 489 patients were enrolled; 34% (p<0.001) of pathway patients were admitted while 20% were placed in the EDOU; 3% (p=0.99) of discharged patients had critical interventions at 30 days and 3% returned (p=0.001).

Conclusion

A focused syncope management pathway effectively reduces hospital admissions and adverse events following discharge and returns to the ED.

[Transient loss of consciousness : Algorithm for the (differential) diagnosis of syncope at emergency department]

Transient loss of consciousness (TLoC) is a common complaint leading to presentation at the emergency department. This comprises a heterogeneous group of disorders including cerebral events, metabolic disturbances, intoxication, psychogenic patterns or any form of syncope. While many causes are benign and self-limited not requiring extensive in-hospital evaluation, others are potentially severe. The optimal evaluation of patients with TLoC/syncope follows a risk-adapted diagnostic algorithm in order to exclude life-threatening conditions and to identify those with high risk for further deterioration like structural heart diseases requiring further diagnostic evaluation. Low-risk patients can be discharged without further extensive diagnostic work up. This article presents an algorithm for structured, evidence-based care of the syncope patient in accordance with the recently launched "2018 ESC guidelines for the diagnosis and management of syncope" in order to ensure that patients requiring hospitalization are managed appropriately and those with benign causes are discharged safely. The English version of this algorithm is available at the end of the article under "Supplementary Material".

Outcomes in syncope research: a systematic review and critical appraisal

Syncope is the common clinical manifestation of different diseases, and this makes it difficult to define what outcomes should be considered in prognostic studies. The aim of this study is to critically analyze the outcomes considered in syncope studies through systematic review and expert consensus. We performed a systematic review of the literature to identify prospective studies enrolling consecutive patients presenting to the Emergency Department with syncope, with data on the characteristics and incidence of short-term outcomes. Then, the strengths and weaknesses of each outcome were discussed by international syncope experts to provide practical advice to improve future selection and assessment. 31 studies met our inclusion criteria. There is a high heterogeneity in both outcome choice and incidence between the included studies. The most commonly considered 7-day outcomes are mortality, dysrhythmias, myocardial infarction, stroke, and rehospitalisation. The most commonly considered 30-day outcomes are mortality, haemorrhage requiring blood transfusion, dysrhythmias, myocardial infarction, pacemaker or implantable defibrillator implantation, stroke, pulmonary embolism, and syncope relapse. We present a critical analysis of the pros and cons of the commonly considered outcomes, and provide possible solutions to improve their choice in ED syncope studies. We also support global initiatives to promote the standardization of patient management and data collection.

Syncope: current knowledge, uncertainties and strategies for management optimisation in the emergency department

Admission rates and expenditures for syncope remain high. This unsatisfactory management could be due to several factors, including lack of evidence-based strategy, poor accuracy of clinical decision rules, difficulty in disseminating guidelines, as well as uncertainties concerning management of intermediate-risk patients and role of observation protocols and syncope units. To optimise management, it has been proposed to adopt a pragmatic, symptoms-based definition of syncope and a classification related to the underlying mechanism rather than suspected aetiology. It has also been emphasised the importance of identifying patients at intermediate risk as they can be safely discharged after an intensive emergency department evaluation. A further improvement might result from a research implementation to validate the role of observation protocols and to select patients amenable to be sent to outpatient syncope units. Finally, future studies on prognostic significance of syncope should be performed with a more careful selection of outcomes and a greater uniformity.

Trends of hospitalizations for syncope/collapse in the United States from 2004 to 2013-An analysis of national inpatient sample

INTRODUCTION

Syncope/collapse is a common reason for emergency department visits, and approximately 30-40% of these individuals are hospitalized. We examined changes in hospitalization rates, in-hospital mortality, and cost of syncope/collapse-related hospital care in the United States from 2004 to 2013.

METHODS

We used the US Nationwide Inpatient Sample (NIS) from 2004 to 2013 to identify syncope/collapse-related hospitalizations using ICD-9, code 780.2, as the principal discharge diagnosis. Data are presented as mean ± SEM.

RESULTS

From 2004 to 2013, there was a 42% reduction in hospitalizations with a principal discharge diagnosis of syncope/collapse from 54,259 (national estimate 253,591) in 2004 to 31,427 (national estimate 156,820) in 2013 (P < 0.0001). The mean length of hospital stays decreased (2.88 ± 0.04 days in 2004 vs. 2.54 ± 0.02 in 2013; P < 0.0001), while in-hospital mortality did not change (0.28% in 2004 vs. 0.18% in 2013; P  =  0.12). However, mean charges (inflation adjusted) for syncope/collapse-related hospitalization increased by 43.6% from $17,514 in 2004 to $25,160 in 2013 (P < 0.0001). The rates of implantation of permanent pacemakers and implantable cardioverter defibrillator remained low during these hospitalizations, and decreased over time (P for both < 0.0001).

CONCLUSIONS

Hospitalization rates for syncope/collapse have decreased significantly in the US from 2004 to 2013. Despite a modest reduction in length of stay, the cost of syncope/collapse-related hospital care has increased.

Predictor variables of abnormal imaging findings of syncope in the emergency department

BACKGROUND

This study aimed to describe the pathological findings and to analyze clinical predictors of abnormal imaging findings in patients presenting to the emergency department (ED) with syncope.

METHODS

The database was retrospectively reviewed for all patients who underwent cranial computed tomography (CT) or magnetic resonance imaging (MRI), having the symptom of syncope. Patients were included only if they were from the emergency department and excluded if were under 18 years of age, had known recent intracranial pathology, known brain tumor, or having a history of trauma. The primary outcome was assumed as abnormal head CT or MRI including intracranial hemorrhage, acute or subacute stroke, and newly diagnosed brain mass. Univariate and multivariate logistic regression analysis was utilized to determine the association between clinical variables and any significant pathology in either CT or MR scan.

RESULTS

Total of 1230 syncope (717 men and 513 women; range, 18-92 years; mean, 54.5 years) as presenting symptoms were identified in patients receiving either cranial CT or MR scan in the ED. Abnormal findings related to the syncope were observed in 47 (3.8%) patients. The following predictor variables were found to be significantly correlated with acutely abnormal head CT and MRI: a focal neurologic deficit, history of malignancy, hypertension, and age greater than 60 years.

CONCLUSIONS

Our data offer that the identification of predictor variables has a potential to decrease the routine use of head CT and MRI in patients admitting to the ED with syncope.

Epidemiology and aetiology of impaired level of consciousness in prehospital nontrauma patients in an urban setting

BACKGROUND

There is little information on the epidemiology and aetiology of nontraumatic loss of consciousness in patients in the Emergency Department, and this high-risk patient group has been poorly characterized in the prehospital setting as well. The aim of this study was to study the epidemiology and aetiology of nontraumatic impaired level of consciousness among the patients treated by an urban Emergency Medical Service (EMS) system in Finland.

METHODS

Data of all emergency calls not related to trauma in an urban EMS system in southern Finland during 2012 were analysed. The inclusion criterion in this study was impaired level of consciousness as identified from the EMS run sheets. Diagnoses made in the receiving facility were cross-checked with the data.

RESULTS

During the study period, the EMS was alerted to 22 184 emergency calls. Of these, 306 calls met the inclusion criterion. The included patients could be categorized into four groups: seizures (32%), diabetes (24%), intoxication (17%) and impaired level of consciousness with no other obvious or specific cause (27%). The overall case fatality rate was 8%.

CONCLUSION

Of all EMS calls, patients who presented with an impaired level of consciousness represented 1.4% of all patients, but the fatality rate in those who remained with an impaired level of consciousness during the prehospital phase was considerable. Impaired level of consciousness was associated with a multitude of aetiologies, of which seizures were the most common.

Diagnostic and Therapeutic Management of a First Unprovoked Seizure in Children and Adolescents With a Focus on the Revised Diagnostic Criteria for Epilepsy

By definition, unprovoked seizures are not precipitated by an identifiable factor, such as fever or trauma. A thorough history and physical examination are essential to caring for pediatric patients with a potential first unprovoked seizure. Differential diagnosis, EEG, neuroimaging, laboratory tests, and initiation of treatment will be reviewed. Treatment is typically initiated after 2 unprovoked seizures, or after 1 seizure in select patients with distinct epilepsy syndromes. Recent expansion of the definition of epilepsy by the ILAE allows for the diagnosis of epilepsy to be made after the first seizure if the clinical presentation and supporting diagnostic studies suggest a greater than 60% chance of a second seizure. This review summarizes the current literature on the diagnostic and therapeutic management of first unprovoked seizure in children and adolescents while taking into consideration the revised diagnostic criteria of epilepsy.

Evaluation of the first seizure patient: Key points in the history and physical examination

PURPOSE

This review will present the history and physical examination as the launching point of the first seizure evaluation, from the initial characterization of the event, to the exclusion of alternative diagnoses, and then to the determination of specific acute or remote causes. Clinical features that may distinguish seizures from alternative diagnoses are discussed in detail, followed by a discussion of acute and remote first seizure etiologies.

METHODS

This review article is based on a discretionary selection of English language articles retrieved by a literature search in the PubMed database, and the authors' clinical experience.

RESULTS

The first seizure is a dramatic event with often profound implications for patients and family members. The initial clinical evaluation focuses on an accurate description of the spell to confirm the diagnosis, along with careful scrutiny for previously unrecognized seizures that would change the diagnosis more definitively to one of epilepsy. The first seizure evaluation rests primarily on the clinical history, and to a lesser extent, the physical examination.

CONCLUSIONS

Even in the era of digital EEG recording and neuroimaging, the initial clinical evaluation remains essential for the diagnosis, treatment, and prognostication of the first seizure.

Transient loss of consciousness assessment in a University Hospital: From diagnosis to prognosis

Background

Transient loss of consciousness (TLoC) is a symptom that has several differential etiologic diagnosis, causes significant morbidity and mortality with impact on quality of life.

Objective

The purpose of this study was to access the diagnosis and prognosis of these patients admitted in a Portuguese University Hospital.

Methods

The study included 125 patients with TLoC admitted in the emergency room and then admitted to the hospital during the year 2013. Patients were contacted by phone for follow-up evaluations, during the 18 months from the date of admission.

Results

Cardiogenic syncope was the most common etiology of TLoC (39.2%). The 18-month overall mortality was 11.2%, however this was higher in patients with unexplained TLoC, with an 18-month mortality of 27.8% (p = 0.031); It was found that half of patients who died, did so in the first month from admission date; 20% of patients had recurrent episodes of TLoC (mean number of 5.6 episodes), with a higher percentage of recurrence occurring in patients with reflex syncope (35.3%; p = 0.023). 60% of patients with recurrent episodes suffered accidents and/or injuries, and 20% of recurrence patients gave up driving (p = 0.019).

Conclusion

The results obtained highlight the burden of TLoC in terms of morbidity and mortality, similar results to those previously published, except for the prevalence of the etiology, cause of death and recurrence's etiology of TLoC. This study emphasizes the significant implications that TLoC leads on morbidity and mortality being essential its accurate diagnosis.

Syncope as a health risk for soldiers - influence of medical history and clinical findings on the sensitivity of head-up tilt table testing

BACKGROUND

Syncope is a relevant health problem in military environments. Reliable diagnosis is challenging. Tilt table testing is an important tool for syncope diagnosis. The aim of this study was to determine whether signs such as prodromal symptoms, co-morbidity, frequency of syncopal events, body length, body mass index, and electrocardiography abnormalities can be used to predict the success of tilt table testing at diagnosing syncope.

METHODS

Data from 100 patients with histories of syncope or pre-syncope, who were diagnosed using head-up tilt table testing, were retrospectively analyzed in a cross-sectional analysis. The diagnostic procedure was based upon a modified version of the Westminster protocol without any pharmacological provocation.

RESULTS

Patients showing pathological reaction patterns during tilt table testing suffered from prodromal symptoms, such as dizziness and sweating, significantly more often. The patients reported more injuries resulting from syncopal events and more previous syncopal events, and the prevalence of co-morbidity was greater among patients presenting negative findings during tilt testing. An asthenic-leptosomal physique was not confirmed as a risk factor for syncopal events as is the case for idiopathic arterial hypotension. However, patients with pathological reaction patterns during tilt table testing were significantly taller. This finding was detected for both females and males. No significant predictors were found in the electrocardiogram (ECG) patterns of patients showing syncope during tilt table testing.

CONCLUSIONS

Frequency of prior syncope and prodromal symptoms, and increased body length with an otherwise good state of health influence the predictive value of tilt table testing for syncope diagnosis. In particular, if these factors are present, tilt table testing should be considered part of the diagnostic algorithm for soldiers with recurrent syncope.

Home Orthostatic Training in Elderly Patients with Vasovagal Syncope - A Prospective Randomised Controlled Trial

Aim: The aim of this study was to assess the effect of home orthostatic training (HOT) on autonomic reflexes in elderly patients with vasovagal syncope (VVS). Methods: Design and Setting: A single-blind randomised control trial was conducted at Eastbourne District General Hospital, East Sussex NHS Trust. Patients: Individuals with recurrent syncope underwent tilt-table testing between August 2007 and October 2009.Those with at least two syncopal episodes and tilt-test proven VVS were recruited. Participants were divided into those aged >65 years (O65) and those aged <65 years (U65). Interventions: Patients in the O65 group were randomised 1:1 to receive active HOT (O65+) or sham HOT (O65-). The U65 group received active HOT. Participants performed HOT/sham HOT and recorded their training and symptoms. Patients had a repeat tilt test at 3 months. Outcome Measures: Time to syncope at repeat tilt-table testing, low-frequency heart rate variability (LF-HRV), high-frequency heart rate variability (HF-HRV), mean upslope baroreflex sensitivity (BRS) and mean downslope BRS were assessed. Results: A total of 106 patients with recurrent syncope underwent tilt-table testing. Of these, 45 consecutive patients (30 in the O65 group and 15 in the U65 group) were recruited. Two, one and three patients withdrew or were lost-to-follow-up in the O65+, O65-, and U65 groups, respectively. Symptomatic benefit occurred in four (31 %) of the O65+, four (29 %) of the O65-, and six (50 %) of the U65. None of the autonomic measures changed significantly in any group. No difference was seen with HF-HRV, LF-HRV mean upslope BRS and mean downslope BRS. Fifty per-cent of the O65+ group stopped training because of back pain. Time constraint (25 %) was the most common reason for cessation in the U65 group. Conclusions: Despite good tilt training compliance, no improvement in autonomic measures in any group was shown. The most common reason for cessation of training was back pain in the elderly groups. This study does not support the use of HOT in elderly patients.

Age and the Head-Up Tilt Test Outcome in Syncope Patients

Background:

The head-up tilt test (HUTT) is a useful diagnostic tool for syncope.

Objectives:

We sought to investigate the outcome of the HUTT in syncope patients and identify the relationship between age and different hemodynamic outcomes.

Patients and Methods:

In this cross-sectional study, we prospectively enrolled consecutive patients who presented with syncope and underwent the HUTT with a clinical suspicion of neurocardiogenic syncope after the exclusion of orthostatic hypotension cases. The HUTT consisted of consecutive passive and active phases. In the passive phase, the patients were tilted at 70 degrees for 20 minutes; and if negative, the test was repeated with 400 micrograms of sublingual nitroglycerin for another 20 minutes. Positive responses were classified according to the classification of the vasovagal syncope international study (VASIS) and compared for age and gender.

Results:

A total of 498 patients were enrolled (age = 44.93 ± 18.77 years; male = 271 [54.4%]). Overall, 291 (58.4%) patients had a positive HUTT, while 256 (88.5%) patients had a positive result during the active phase. The test results were as follows: 107 (36.7%) mixed type (VASIS I), 103 (35.3%) cardioinhibitory (VASIS IIA = 44 [15.1%]; VASIS IIB = 59 [20.2%]), and 80 (27.4%) vasodepressive (VASIS III). There was no relationship between gender and syncope type. The trend of the HUTT result significantly changed with age, and the rate of cardioinhibitory syncope decreased after middle ages (P value for trend = 0.02).

Conclusions:

Hemodynamic response to the HUTT was associated with age. Cardioinhibitory response became less frequent with age due to exaggerated vagal activity in the younger patients as compared with the older subjects.