Is our initial evaluation of patients admitted for syncope guideline-directed and cost-effective?

The Characteristics of Syncope-Related Emergency Department Visits: Resource Utilization and Admission Rate Patterns in Emergency Departments

Background and objective

Decision-making about syncope patients presenting to the emergency department (ED) is challenging since physicians must balance the minimal risks of life-threatening conditions with the unessential use of expensive imaging or unnecessary hospitalizations. This study aimed to determine the characteristics of ED visits, resource utilization, and admission rate patterns related to syncope in the United States (US) during the period 2005-2015.

Methods

Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) on ED visits during the 11-year period from 2005 to 2015 were retrieved. ED visits for syncope were identified and compared against non-syncope ED visits. The demographic and clinical characteristics of patients, as well data on resource allocation and admission trends were captured and described for the syncope and the non-syncope groups.

Results

Syncope accounted for 1.11% of the total ED visits during the study period from 2005 to 2015. The incidence of syncope-related ED visits was higher among elderly females, whites, and non-Hispanics. The trend of admission rates showed a decline from about 30% in 2005-2010 to less than 20% in 2014 and 2015. Advanced imaging (CT or MRI) was ordered for 34% of syncope patients.

Conclusion

The percentage of syncope-related ED visits remained stable during the study period, but the admission rates declined while the use of advanced imaging in syncope-related ED visits remained substantially high despite the advances in research and availability of clinical guidelines. Future research is needed to rationalize healthcare utilization in syncope-related ED visits and precisely identify the high-risk population.

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.