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Möckel M, Janssens K, Pudasaini S, Garcia-Castrillo Riesgo L, Moya Torrecilla F, Golea A, Reed MJ, Karamercan M, Fernández Cejas JA, Laribi S. The syncope core management process in the emergency department: a consensus statement of the EUSEM syncope group. Eur J Emerg Med 2024:00063110-990000000-00131. [PMID: 38874507 DOI: 10.1097/mej.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
The European Society of Cardiology issued updated syncope guidelines in 2018 which included recommendations for managing syncope in the emergency department (ED) setting. However, these guidelines lack detailed process-oriented instructions regarding the fact that ED syncope patients initially present with a transient loss of consciousness (TLOC), which can have a broad spectrum of causes. This study aims to establish a European consensus on the general process of the workup and care for patients with suspected syncope and provides rules for sufficient and systematic management of the broad group of syncope (initially presenting as TLOC) patients in the ED. A variety of European diagnostic and therapeutic standards for syncope patients were reviewed and summarized in three rounds of a modified Delphi process by the European Society for Emergency Medicine syncope group. Based on a consensus statement, a detailed process pathway is created. The primary outcome of this work is the presentation of a universal process pathway for the structured management of syncope patients in European EDs. The here presented extended event process chain (eEPC) summarizes and homogenizes the process management of European ED syncope patients. Additionally, an exemplary translation of the eEPC into a practice-based flowchart algorithm, which can be used as an example for practical use in the ED, is provided in this work. Syncope patients, initially presenting with TLOC, are common and pose challenges in the ED. Despite variations in process management across Europe, the development of a universally applicable syncope eEPC in the ED was successfully achieved. Key features of the consensus and eEPC include ruling out life-threatening causes, distinguishing syncope from nonsyncopal TLOCs, employing syncope risk stratification categories and based on this, making informed decisions regarding admission or discharge.
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Affiliation(s)
- Martin Möckel
- Department of Emergency and Acute Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kelly Janssens
- Department of Emergency Medicine, St. Vincents University Healthcare Group, Dublin, Ireland
| | - Samipa Pudasaini
- Department of Emergency and Acute Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Francisco Moya Torrecilla
- Vithas Xanit International Hospital and Clinical Lead, International Medical Services Vithas Xanit International Hospital Benalmadena, Malaga, Spain
| | - Adela Golea
- University of Medicine and Pharmacy Cluj, Emergency Unit - University Emergency County Hospital, Cluj Napoca, Romania
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Acute Care Edinburgh, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Mehmet Karamercan
- Department of Emergency Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | | | - Said Laribi
- Emergency Medicine Department, Tours University Hospital, Tours, France
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2
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Francisco-Pascual J, Lal-Trehan Estrada N. Syncope. Med Clin (Barc) 2024:S0025-7753(24)00031-9. [PMID: 38388319 DOI: 10.1016/j.medcli.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 02/24/2024]
Affiliation(s)
- Jaume Francisco-Pascual
- Unitat d'Arrítmies, Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, España.
| | - Nisha Lal-Trehan Estrada
- Unitat d'Arrítmies, Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España
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Jung C, Boeken U, Schulze PC, Frantz S, Hermes C, Kill C, Marohl R, Voigt I, Wolfrum S, Bernhard M, Michels G. [Monitoring of emergency cardiovascular patients in the emergency department : Consensus paper of the DGK, DGINA and DGIIN]. Med Klin Intensivmed Notfmed 2023; 118:47-58. [PMID: 37712970 DOI: 10.1007/s00063-023-01069-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 09/16/2023]
Abstract
Patients with potential or proven cardiovascular diseases represent a relevant proportion of the total spectrum in the emergency department. Their monitoring for cardiovascular surveillance until the diagnostics and acute treatment are initiated, often poses an interdisciplinary and interprofessional challenge, because resources are limited, nevertheless a high level of patient safety has to be ensured and the correct procedure has a major prognostic significance. This consensus paper provides an overview of the practical implementation, the modalities of monitoring and the application in a selection of cardiovascular diagnoses. The article provides specific comments on the clinical presentations of acute coronary syndrome, acute heart failure, cardiogenic shock, hypertensive emergency events, syncope, acute pulmonary embolism and cardiac arrhythmia. The level of evidence is generally low as no randomized trials are available on this topic. The recommendations are intended to supplement or establish local standards and to assist all physicians, nursing personnel and the patients to be treated in making decisions about monitoring in the emergency department.
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Affiliation(s)
- Christian Jung
- Klinik für Kardiologie, Pneumologie und Angiologie des Universitätsklinikums Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - Udo Boeken
- Klinik für Herzchirurgie des Universitätsklinikums Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - P Christian Schulze
- Klinik für Innere Medizin I des Universitätsklinikums Jena, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - Stefan Frantz
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
- Kommission für Klinische Kardiovaskuläre Medizin, Deutsche Gesellschaft für Kardiologie, Düsseldorf, Deutschland
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Deutschland
| | - Clemens Kill
- Zentrum für Notfallmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - Ranka Marohl
- Klinik für Notfall- und Akutmedizin/Interdisziplinäre Notfallambulanz, Krankenhaus Porz am Rhein, Köln, Deutschland
| | - Ingo Voigt
- Klinik für Akut- und Notfallmedizin, Elisabeth-Krankenhaus Essen, Essen, Deutschland
| | - Sebastian Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikum Schleswig-Holstein am Campus Lübeck, Lübeck, Deutschland
| | - Michael Bernhard
- Zentrale Notaufnahme des Universitätsklinikums Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Guido Michels
- Zentrum für Notaufnahme, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus Trier der Universitätsmedizin Mainz, Trier, Deutschland
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Thiruganasambandamoorthy V, Keller M, Nguyen PAI, Gupta P, Ghaedi B, Cao GZQ, Cheung WJ, Khatiwada B, Nemnom MJ, Yadav K, Eagles D, Brehaut J, Tarhuni W, Rouleau G, Desveaux L, Taljaard M. Implementation of the Canadian syncope pathway: a pilot non-randomized stepped wedge trial. CAN J EMERG MED 2023; 25:808-817. [PMID: 37651075 DOI: 10.1007/s43678-023-00570-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/26/2023] [Indexed: 09/01/2023]
Abstract
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.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Maria Keller
- Emergency Department, Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Phuong Anh Iris Nguyen
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Preeti Gupta
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Bahareh Ghaedi
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - George Z Q Cao
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Warren J Cheung
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Bikalpa Khatiwada
- Emergency Department, Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jamie Brehaut
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Wadea Tarhuni
- Canadian Cardiac Care, Windsor, ON, Canada
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Genevieve Rouleau
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Université du Québec en Outaouais, St-Jérôme, QB, Canada
| | - Laura Desveaux
- Institute for Better Health & Learning Health System Program Lead, Trillium Health Partners, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Monica Taljaard
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Francisco Pascual J, Jordan Marchite P, Rodríguez Silva J, Rivas Gándara N. Arrhythmic syncope: From diagnosis to management. World J Cardiol 2023; 15:119-141. [PMID: 37124975 PMCID: PMC10130893 DOI: 10.4330/wjc.v15.i4.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/02/2023] [Accepted: 04/10/2023] [Indexed: 04/20/2023] Open
Abstract
Syncope is a concerning symptom that affects a large proportion of patients. It can be related to a heterogeneous group of pathologies ranging from trivial causes to diseases with a high risk of sudden death. However, benign causes are the most frequent, and identifying high-risk patients with potentially severe etiologies is crucial to establish an accurate diagnosis, initiate effective therapy, and alter the prognosis. The term cardiac syncope refers to those episodes where the cause of the cerebral hypoperfusion is directly related to a cardiac disorder, while arrhythmic syncope is cardiac syncope specifically due to rhythm disorders. Indeed, arrhythmias are the most common cause of cardiac syncope. Both bradyarrhythmia and tachyarrhythmia can cause a sudden decrease in cardiac output and produce syncope. In this review, we summarized the main guidelines in the management of patients with syncope of presumed arrhythmic origin. Therefore, we presented a thorough approach to syncope work-up through different tests depending on the clinical characteristics of the patients, risk stratification, and the management of syncope in different scenarios such as structural heart disease and channelopathies.
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Affiliation(s)
- Jaume Francisco Pascual
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- Grup de Recerca Cardiovascular, Vall d’Hebron Institut de Recerca, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Pablo Jordan Marchite
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Jesús Rodríguez Silva
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Nuria Rivas Gándara
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
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6
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Hudek N, Brehaut JC, Rowe BH, Nguyen PA, Ghaedi B, Ishimwe AC, Fabian C, Yan JW, Sivilotti MLA, Ohle R, Le Sage N, Mercier E, Archambault PM, Plourde M, Davis P, McRae AD, Hegdekar M, Thiruganasambandamoorthy V. Development of practice recommendations based on the Canadian Syncope Risk Score and identification of barriers and facilitators for implementation. CAN J EMERG MED 2023; 25:434-444. [PMID: 37058217 DOI: 10.1007/s43678-023-00498-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/19/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Wide variations in emergency department (ED) syncope management exist. The Canadian Syncope Risk Score (CSRS) was developed to predict the probability of 30-day serious outcomes after ED disposition. Study objectives were to evaluate the acceptability of proposed CSRS practice recommendations among providers and patients, and identify barriers and facilitators for CSRS use to guide disposition decisions. METHODS We conducted semi-structured interviews with 41 physicians involved in ED syncope and 35 ED patients with syncope. We used purposive sampling to ensure a variety of physician specialties and CSRS patient risk levels. Thematic analysis was completed by two independent coders with consensus meetings to resolve conflicts. Analysis proceeded in parallel with interviews until data saturation. RESULTS The majority (97.6%; 40/41) of physicians agreed with discharge of low risk (CSRS ≤ 0) but opined that 'no follow up' changed to 'follow-up as needed'. Physicians indicated current practices do not align with the medium-risk recommendation to discharge patients with 15-day monitoring (CSRS = 1-3; due to lack of access to monitors and timely follow-up) and the high-risk recommendation (CSRS ≥ 4) to potentially discharge patients with 15-day monitoring. Physicians recommended brief hospitalization of high-risk patients due to patient safety concerns. Facilitators included the CSRS-based patient education and scores supporting their clinical gestalt. Patients reported receiving varying levels of information regarding syncope and post-ED care, were satisfied with care received and preferred less resource intensive options. CONCLUSION Our recommendations based on the study results were: discharge of low-risk patients with physician follow-up as needed; discharge of medium-risk patients with 15-day cardiac monitoring and brief hospitalization of high-risk patients with 15-day cardiac monitoring if discharged. Patients preferred less resource intensive options, in line with CSRS recommended care. Implementation should leverage identified facilitators (e.g., patient education) and address the barriers (e.g., monitor access) to improve ED syncope care.
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Affiliation(s)
- Natasha Hudek
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jamie C Brehaut
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | | | | | | | - Christopher Fabian
- Department of Emergency Medicine, The Montfort Hospital, Ottawa, ON, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, ON, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine and Biomedical, and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Robert Ohle
- Departments of Emergency Medicine, Health Science North, Sudbury, ON, Canada
- Health Sciences North Research Institute, Sudbury, ON, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- VITAM-Centre de recherche en santé durable, Québec, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
| | - Patrick M Archambault
- Departments of Family Medicine and Emergency Medicine and Anesthesiology and Intensive Care Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Miville Plourde
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- Department of Family Medicine and Emergency Medicine, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program-Emergency Medicine, Department of Emergency Medicine, Clinical Epidemiology Unit, The Ottawa Hospital Research Institute, University of Ottawa, 1053 Carling Avenue, Ottawa, ON, F6K1Y 4E9, Canada.
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Reed MJ, Grubb N, Lang C, Goodacre S, O'Brien R, Weir CJ, Thokala P, Freeman N, Blackstock C, Dinsmore L, Boyd J, Adamestam I, Macrae P, Hannigan R, Lobban T. Multicentre open label randomised controlled trial of immediate enhanced ambulatory ECG monitoring versus standard monitoring in acute unexplained syncope patients: the ASPIRED study. BMJ Open 2023; 13:e069530. [PMID: 36822806 PMCID: PMC9950891 DOI: 10.1136/bmjopen-2022-069530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION Diagnosing underlying arrhythmia in emergency department (ED) syncope patients is difficult. There is a evidence that diagnostic yield for detecting underlying arrhythmia is highest when cardiac monitoring devices are applied early, ideally at the index visit. This strategy has the potential to change current syncope management from low diagnostic yield Holter to higher yield ambulatory monitoring, reduce episodes of syncope, reduce risk of recurrence and its potential serious consequences, reduce hospital admissions, reduce overall health costs and increase quality of life by allowing earlier diagnosis, treatment and exclusion of clinically important arrhythmias. METHODS AND ANALYSES This is a UK open prospective parallel group multicentre randomised controlled trial of an immediate 14-day ambulatory patch heart monitor vs standard care in 2234 patients presenting acutely with unexplained syncope. Our patient focused primary endpoint will be number of episodes of syncope at 1 year. Health economic evaluation will estimate the incremental cost per syncope episode avoided and quality-adjusted life year gained. ETHICS AND DISSEMINATION Informed consent for participation will be sought. The ASPIRED trial received a favourable ethical opinion from South East Scotland Research Ethics Committee 01 (21/SS/0073). Results will be disseminated via scientific publication, lay summary and visual abstract. TRIAL REGISTRATION NUMBER ISRCTN 10278811.
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Affiliation(s)
- Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
- Acute Care Edinburgh, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Neil Grubb
- Department of Cardiology, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Chris Lang
- Department of Cardiology, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rachel O'Brien
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nicola Freeman
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Caroline Blackstock
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lynn Dinsmore
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Imad Adamestam
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Pam Macrae
- ASPIRED study Patient Advisory Group, Edinburgh, UK
| | | | - Trudie Lobban
- ASPIRED study Patient Advisory Group, Edinburgh, UK
- Arrhythmia Alliance, Chipping Norton, UK
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8
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Alotaibi A, Alakhfash GA, Alakhfash A, Mahmoud T, Alakhfash AA, Al Qwaee A, Mesned A. The Value of Continuous Electrocardiographic Monitoring in Pediatric Cardiology: A Local Center Experience. Cureus 2022; 14:e25667. [PMID: 35812585 PMCID: PMC9256012 DOI: 10.7759/cureus.25667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives This study aims to evaluate the value of Holter monitoring in pediatric cases and look for the best predictor for abnormal Holter monitoring. Methodology All patients referred with cardiac symptoms associated or possibly related to abnormal cardiac rhythm from January 2019 to December 2020 were retrospectively reviewed. The demographic, clinical, 12-lead electrocardiography (ECG), echocardiography, and Holter monitoring results were reviewed. Multinomial logistic regression analysis was used to assess the correlation between gender, age, type of symptoms, ECG, and echo abnormalities, and Holter monitoring results were analyzed. Results During the study period, a total of 189 Holter monitoring was performed for 187 patients. The mean age at the performance of Holter monitoring was 88.6 ± 57 months. The female/male ratio was 1.5:1. The commonest indications for Holter monitoring were abnormal 12-lead ECG (30.7%), palpitations (30.7%), syncopal attacks (12.7%), and chest pain (6.9%). Patients with congenital heart disease (CHD) pre- or post-cardiac intervention constitute 9% of the total Holter monitoring cases. Apart from sinus arrhythmia, 12-lead ECG was abnormal in 57 (30%) patients, with premature atrial complexes (PACs) being the most common abnormality. Echocardiography was abnormal in 67 (35.4%) cases, with secundum atrial septal defect (ASD) (6.3%) and mitral valve prolapse (5.8%) being the commonest abnormalities. The Holter monitoring was completely normal in 89 (47.1%) cases. The commonest Holter abnormalities were PACs (12.7%), supraventricular tachycardia (SVT) (5.8%), and premature ventricular complexes (PVCs) (4.8%). There were 24 patients with SVT, and eight of them had normal Holter monitoring. One patient with SVT had ablation by the electrophysiologist. Using the multinomial logistic regression analysis, significantly abnormal 12-lead ECG, the presence of CHD, and abnormal echocardiography predict the presence of abnormal Holter results with a statistically significant p-value. Conclusion Most pediatric arrhythmias are benign. Holter monitoring provides reassurance for the patient and family. Abnormal Holter monitoring is more often observed in patients with paroxysmal or persistently abnormal 12-lead ECG with or without associated cardiac abnormalities or cardiac interventions. The yield of Holter monitoring is low in children referred because of chest pain, palpitations, or syncope with no other cardiac symptoms and with a structurally and functionally normal heart.
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Ojha U, Ayathamattam J, Okonkwo K, Ogunmwonyi I. Recent Updates and Technological Developments in Evaluating Cardiac Syncope in the Emergency Department. Curr Cardiol Rev 2022; 18:e210422203887. [PMID: 35593355 PMCID: PMC9893151 DOI: 10.2174/1573403x18666220421110935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/21/2022] [Accepted: 02/24/2022] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Utkarsh Ojha
- Department of Cardiology, Royal Brompton & Harefield Hospitals, England, UK
| | - James Ayathamattam
- Department of Medicine, Royal Lancaster Infirmary, Lancaster, United Kingdom
| | - Kenneth Okonkwo
- Department of Medicine, Royal Lancaster Infirmary, Lancaster, United Kingdom
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Gu Q, Chen Z, Ma J, Zhou Y, Li J, Ying L, Hua R, Zhang W, Li R, Zou F, Gong X, Zhan Y, Li C. Use of handheld electrocardiograph (SnapECG) for the remote monitoring of arrhythmias. Digit Health 2022; 8:20552076221113393. [PMID: 35860612 PMCID: PMC9290110 DOI: 10.1177/20552076221113393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the value of a SnapECG monitoring in diagnosing arrhythmias compared with the conventional management. Methods In the first phase, the SnapECG and 12-lead electrocardiogram (ECG) were simultaneously adopted to detect arrhythmias in 439 hospitalized patients. The accuracies of the SnapECG in detecting different arrhythmias were assessed. In the second phase, 62 patients with palpitations were randomized to receive the SnapECG monitoring or conventional management for 3 months. The diagnosis rate, time of diagnosis, episodes before diagnosis, associated expenses, and scores of the modified European Heart Rhythm Association (EHRA), Self-rating Anxiety Scale (SAS), and the 36-item short-form health survey questionnaire (SF-36) were compared between groups. Results In the first phase, the SnapECG monitoring showed a sensitivity of 83.55% and specificity of 96.79% in identifying tachyarrhythmias, and a sensitivity of 95.29% and specificity of 97.54% in identifying bradyarrhythmias. In the second phase, 1642 ECGs were recorded by the SnapECG, among which 290 abnormal ECGs were identified. Compared with the conventional management, the SnapECG monitoring increased the diagnosis rate of symptomatic arrhythmias (70.97% vs. 19.35%, P < 0.05), shortened the time of diagnosis (48.26 ± 36.78 days vs. 71.45 ± 30.01 days, P < 0.05) and consequently reduced the episodes of symptomatic arrhythmias prior to establishing diagnosis. The scores of modified EHRA, SAS, SF-36 significantly improved at 3-month compared with their baseline levels in the SnapECG group. Conclusions Remote monitoring with the SnapECG can achieve early diagnosis of symptomatic arrhythmias. However, its sensitivity in identifying P-wave-related arrhythmias warrants further improvement.
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Affiliation(s)
- Qian Gu
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.,Qian Gu, Zengguang Chen, Jiazheng Ma, and Yaqing Zhou contributed equally to this work
| | - Zengguang Chen
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.,The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China.,Qian Gu, Zengguang Chen, Jiazheng Ma, and Yaqing Zhou contributed equally to this work
| | - Jiazheng Ma
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.,Qian Gu, Zengguang Chen, Jiazheng Ma, and Yaqing Zhou contributed equally to this work
| | - Yaqing Zhou
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.,Qian Gu, Zengguang Chen, Jiazheng Ma, and Yaqing Zhou contributed equally to this work
| | - Jinshuang Li
- Suqian Hospital Affiliated of Xuzhou Medical University, Suqian, Jiangsu, China
| | - Lianghong Ying
- Huai'an Hospital Affiliated of Xuzhou Medical University, Jiangsu, China
| | - Rui Hua
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Wenhao Zhang
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ran Li
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | | | - Xiaoxuan Gong
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yiyang Zhan
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chunjian Li
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111235. [PMID: 34833453 PMCID: PMC8623370 DOI: 10.3390/medicina57111235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/04/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients’ data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7–10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7–10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7–10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7–10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial.
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Thiruganasambandamoorthy V, Yan JW, Rowe BH, Mercier É, Le Sage N, Hegdekar M, Finlayson A, Huang P, Mohammad H, Mukarram M, Nguyen PAI, Syed S, McRae AD, Nemnom MJ, Taljaard M, Silviotti MLA. Personalised risk prediction following emergency department assessment for syncope. Emerg Med J 2021; 39:501-507. [PMID: 34740890 DOI: 10.1136/emermed-2020-211095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/26/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions. METHODS We pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids. RESULTS 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS -3 to -2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score -3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%-6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs CONCLUSIONS: 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Éric Mercier
- Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne Finlayson
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Huang
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Hassan Mohammad
- Faculty of Technology and Trades, Algonquin College, Ottawa, Ontario, Canada
| | - Muhammad Mukarram
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Phuong Anh Iris Nguyen
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shahbaz Syed
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Marco LA Silviotti
- Departments of Emergency Medicine and Biomedical, and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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13
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Chan J, Ballard E, Brain D, Hocking J, Yan A, Morel D, Hunter J. External validation of the Canadian Syncope Risk Score for patients presenting with undifferentiated syncope to the emergency department. Emerg Med Australas 2021; 33:418-424. [PMID: 33052034 DOI: 10.1111/1742-6723.13641] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/08/2020] [Accepted: 08/29/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To validate the accuracy and safety of the Canadian Syncope Risk Score (CSRS) for patients presenting with syncope. METHODS Single centre prospective observational study in Brisbane, Australia. Adults presenting to the ED with syncope within the last 24 h were recruited after applying exclusion criteria. Study was conducted over 1 year, from March 2018 to March 2019. Thirty-day serious adverse events (SAE) were reported based on the original derivation study and standardised outcome reporting for syncope. Individual patient CSRS was calculated and correlated with 30-day SAE and disposition status from ED. RESULTS Two hundred and eighty-three patients were recruited to the study. Average age was 55.6 years (SD 22.7 years), 37.1% being male with a 39.9% admission rate. Thirty-day SAE occurred in seven patients (2.5%) and no recorded deaths. The CSRS performed with a sensitivity of 71.4% (95% confidence interval [CI] 30.3-94.9%), specificity 72.8% (95% CI 67.1-77.9%) for a threshold score of 1 or higher. CONCLUSION Syncope patients in our study were predominantly very low to low risk (72%). The prevalence of 30-day SAE was low, majority occurring following hospital discharge. Sensitivity estimates for CSRS was lower than the derivation study but lacked robustness with wide CIs because of a small sample size and number of events observed. However, the CSRS did not miss any clinically relevant outcomes in low risk patients making it potentially useful in aiding their disposition. Larger validation studies in Australia are encouraged to further test the diagnostic accuracy of the CSRS.
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Affiliation(s)
- Jason Chan
- Emergency Department, Redcliffe Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Emma Ballard
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - David Brain
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julia Hocking
- Griffith University, Brisbane, Queensland, Australia
| | - Alan Yan
- Emergency Department, Redcliffe Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Douglas Morel
- Emergency Department, Redcliffe Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jonathan Hunter
- Emergency Department, Redcliffe Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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A Rational Evaluation of the Syncope Patient: Optimizing the Emergency Department Visit. ACTA ACUST UNITED AC 2021; 57:medicina57060514. [PMID: 34064050 PMCID: PMC8224075 DOI: 10.3390/medicina57060514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/13/2022]
Abstract
Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a structured approach to the syncope patient in the emergency department, highlighting the evidence supporting the role of clinical judgement and the initial electrocardiogram (ECG) in making the preliminary diagnosis and in safely identifying the patients at low risk of short- and long-term adverse events or admitting the patient if likely to benefit from urgent intervention. Clinical decision tools and additional testing may aid in further stratifying patients and may guide disposition. While hospital admission does not seem to offer additional mortality benefit, the efficient utilization of outpatient testing may provide similar diagnostic yield, preventing unnecessary hospitalizations.
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Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2021; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 497] [Impact Index Per Article: 165.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Rosenberg H, Nath A, Thiruganasambandamoorthy V. Just the facts: how to assess a patient presenting to the emergency department with syncope. CAN J EMERG MED 2021; 23:286-290. [PMID: 33689119 DOI: 10.1007/s43678-021-00095-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/29/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Hans Rosenberg
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Hospital, Ottawa, ON, Canada.
| | - Avik Nath
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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17
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Calder LA, Perry J, Yan JW, De Gorter R, Sivilotti MLA, Eagles D, Myslik F, Borgundvaag B, Émond M, McRae AD, Taljaard M, Thiruganasambandamoorthy V, Cheng W, Forster AJ, Stiell IG. Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study. Ann Emerg Med 2021; 77:561-574. [PMID: 33612283 DOI: 10.1016/j.annemergmed.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope. METHODS This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes. RESULTS Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses. CONCLUSION Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.
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Affiliation(s)
- Lisa A Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Ria De Gorter
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcel Émond
- Département de médecine Familiale et d'Urgence, Université Laval, Québec City, Quebec, Canada
| | - Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan J Forster
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Thiruganasambandamoorthy V, Sivilotti MLA. Web Exclusive. Annals for Hospitalists Inpatient Notes - Identifying High-Risk Patients With Syncope-What Hospitalists Need to Know. Ann Intern Med 2021; 174:HO2-HO3. [PMID: 33587884 DOI: 10.7326/m20-8081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Krishnan RJ, Mukarram M, Ghaedi B, Sivilotti MLA, Le Sage N, Yan JW, Huang P, Hegdekar M, Mercier E, Nemnom MJ, Calder LA, McRae AD, Rowe BH, Wells GA, Thiruganasambandamoorthy V. Benefit of hospital admission for detecting serious adverse events among emergency department patients with syncope: a propensity-score-matched analysis of a multicentre prospective cohort. CMAJ 2020; 192:E1198-E1205. [PMID: 33051314 PMCID: PMC7588246 DOI: 10.1503/cmaj.191637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The benefit of hospital admission after emergency department evaluation for syncope is unclear. We sought to determine the association between hospital admission and detection of serious adverse events, and whether this varied according to the Canadian Syncope Risk Score (CSRS). METHODS We conducted a secondary analysis of a multicentre prospective cohort of patients assessed in the emergency department for syncope. We compared patients admitted to hospital and discharged patients, using propensity scores to match 1:1 for risk of a serious adverse event. The primary outcome was detection of a serious adverse event in hospital for admitted patients or within 30 days after emergency department disposition for discharged patients. RESULTS We included 8183 patients, of whom 743 (9.1%) were admitted; 658/743 (88.6%) were matched. Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0, 95% confidence interval [CI] 3.3-7.4), nonfatal arrhythmia (OR 5.1, 95% CI 2.9-8.8) and nonarrhythmic serious adverse event (OR 6.3, 95% CI 2.9-13.5). There were no significant differences between the 2 groups in death (OR 1.0, 95% CI 0.4-2.7) or detection of ventricular arrhythmia (OR 2.0, 95% CI 0.7-6.0). Differences between admitted and discharged patients in detection of serious adverse events were greater for those with a CSRS indicating medium to high risk (p = 0.04). INTERPRETATION Patients with syncope were more likely to have serious adverse events identified within 30 days if they were admitted to hospital rather than discharged from the emergency department. However, the benefit of hospital admission is low for patients at low risk of a serious adverse event.
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Affiliation(s)
- Rohin J Krishnan
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Muhammad Mukarram
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Bahareh Ghaedi
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Marco L A Sivilotti
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Natalie Le Sage
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Justin W Yan
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Paul Huang
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Mona Hegdekar
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Eric Mercier
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Marie-Joe Nemnom
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Lisa A Calder
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Andrew D McRae
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Brian H Rowe
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - George A Wells
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Venkatesh Thiruganasambandamoorthy
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.
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20
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Sandhu RK, Raj SR, Thiruganasambandamoorthy V, Kaul P, Morillo CA, Krahn AD, Guzman JC, Sheldon RS, Banijamali HS, MacIntyre C, Manlucu J, Seifer C, Sivilotti M. Canadian Cardiovascular Society Clinical Practice Update on the Assessment and Management of Syncope. Can J Cardiol 2020; 36:1167-1177. [PMID: 32624296 DOI: 10.1016/j.cjca.2019.12.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/19/2019] [Accepted: 12/22/2019] [Indexed: 10/23/2022] Open
Abstract
Syncope is a symptom that occurs in multiple settings and has a variety of underlying causes, ranging from benign to life threatening. Determining the underlying diagnosis and prognosis can be challenging and often results in an unstructured approach to evaluation, which is ineffective and costly. In this first ever document, the Canadian Cardiovascular Society (CCS) provides a clinical practice update on the assessment and management of syncope. It highlights similarities and differences between the 2017 American College of Cardiology/American Heart Association/Heart Rhythm Society and the 2018 European Society of Cardiology guidelines, draws on new data following a thorough review of medical literature, and takes the best available evidence and clinical experience to provide clinical practice tips. Where appropriate, a focus on a Canadian perspective is emphasized in order to illuminate larger international issues. This document represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific advice. The primary writing panel wrote the document, followed by peer review from the secondary writing panel. The CCS Guidelines Committee reviewed and approved the statement. The practice tips represent the consensus opinion of the primary writing panel authors, endorsed by the CCS. The CCS clinical practice update on the assessment and management of syncope focuses on epidemiology, the initial evaluation including risk stratification and disposition from the emergency department, initial diagnostic work-up, management of vasovagal syncope and orthostatic hypotension, and syncope and driving.
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Affiliation(s)
| | - Roopinder K Sandhu
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.
| | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Carlos A Morillo
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Juan C Guzman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Hamid S Banijamali
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Ciorsti MacIntyre
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jaimie Manlucu
- Division of Cardiology, Western University, London, Ontario, Canada
| | - Colette Seifer
- Division of Cardiology, University of Winnipeg, Winnipeg, Manitoba, Canada
| | - Marco Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
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21
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Thiruganasambandamoorthy V, McRae AD, Rowe BH, Sivilotti MLA, Mukarram M, Nemnom MJ, Booth RA, Calder LA, Stiell IG, Wells GA, Cheng W, Taljaard M. Does N-Terminal Pro-B-Type Natriuretic Peptide Improve the Risk Stratification of Emergency Department Patients With Syncope? Ann Intern Med 2020; 172:648-655. [PMID: 32340039 DOI: 10.7326/m19-3515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Studies have reported that natriuretic peptides provide prognostic information for emergency department (ED) syncope. OBJECTIVE To evaluate whether adding N-terminal pro-B-type natriuretic peptide (NT-proBNP) to the Canadian Syncope Risk Score (CSRS) improves prediction of 30-day serious adverse events (SAEs). DESIGN Prospective cohort study. SETTING 6 EDs in 2 Canadian provinces. PARTICIPANTS 1452 adult ED patients with syncope. INTERVENTION Serum NT-proBNP was measured locally at 1 site and batch processed at a central laboratory from other sites. The concentrations were not available to treating physicians or for adjudication of outcomes. MEASUREMENTS An adjudicated composite outcome of 30-day SAEs, including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events. RESULTS Of 1452 patients enrolled, 152 (10.5% [95% CI, 9.0% to 12.1%]) had 30-day SAEs, 57 (3.9%) of which were identified after the index ED disposition. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them (median, 626.5 ng/L vs. 81 ng/L; P < 0.001). Adding NT-proBNP values to the CSRS did not significantly improve prognostication (c-statistic, 0.89 and 0.90; P = 0.12 for difference), regardless of SAE subgroup or whether the SAE was identified after the index ED visit. The net reclassification index shows that NT-proBNP would have correctly reclassified 3% of patients with SAEs at the expense of incorrectly reclassifying 2% of patients without SAEs. LIMITATIONS Our study was powered to detect a 3% difference in the area under the curve. The heterogeneity of outcomes and robust baseline discrimination by the CSRS will make improvements challenging. CONCLUSION Although serum NT-proBNP concentrations were generally much higher among ED patients with syncope who had a 30-day SAE, this blood test added little new information to the CSRS. Routine use of NT-proBNP for ED syncope prognostication is not recommended. PRIMARY FUNDING SOURCE Physicians' Services Incorporated Foundation, Canadian Institutes of Health Research, and The Ottawa Hospital Academic Medical Organization.
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Affiliation(s)
| | - Andrew D McRae
- University of Calgary, Calgary, Alberta, Canada (A.D.M.)
| | - Brian H Rowe
- University of Alberta, Edmonton, Alberta, Canada (B.H.R.)
| | | | | | | | - Ronald A Booth
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Lisa A Calder
- University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (V.T., L.A.C., I.G.S.)
| | - Ian G Stiell
- University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (V.T., L.A.C., I.G.S.)
| | - George A Wells
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Wei Cheng
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Monica Taljaard
- The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (M.T.)
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22
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Thiruganasambandamoorthy V, Sivilotti MLA, Le Sage N, Yan JW, Huang P, Hegdekar M, Mercier E, Mukarram M, Nemnom MJ, McRae AD, Rowe BH, Stiell IG, Wells GA, Krahn AD, Taljaard M. Multicenter Emergency Department Validation of the Canadian Syncope Risk Score. JAMA Intern Med 2020; 180:737-744. [PMID: 32202605 PMCID: PMC7091474 DOI: 10.1001/jamainternmed.2020.0288] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use. OBJECTIVE To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018. MAIN OUTCOMES AND MEASURES Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated. RESULTS A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively. CONCLUSIONS AND RELEVANCE The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.,University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada.,CHU de Québec - Université Laval Research Center, Quebec City, Quebec, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Paul Huang
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada.,CHU de Québec - Université Laval Research Center, Quebec City, Quebec, Canada
| | - Muhammad Mukarram
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Marie-Joe Nemnom
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.,University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - George A Wells
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.,University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
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23
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Solbiati M, Dipaola F, Villa P, Seghezzi S, Casagranda I, Rabajoli F, Fiorini E, Porta L, Casazza G, Voza A, Barbic F, Montano N, Furlan R, Costantino G. Predictive Accuracy of Electrocardiographic Monitoring of Patients With Syncope in the Emergency Department: The SyMoNE Multicenter Study. Acad Emerg Med 2020; 27:15-23. [PMID: 31854141 DOI: 10.1111/acem.13842] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/14/2019] [Accepted: 07/25/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Arrhythmia is one of the most worrisome causes of syncope. Electrocardiographic (ECG) monitoring is crucial for the management of non-low-risk patients in the emergency department (ED). However, its diagnostic accuracy and optimal duration are unknown. We aimed to assess the diagnostic accuracy of ECG monitoring in non-low-risk patients with syncope in the ED. METHODS This prospective multicenter observational study included adult patients presenting to the ED after syncope. Patients without an obvious etiology after ED evaluation who were classified by ED physicians as being at non-low risk of adverse events underwent ECG monitoring. We assessed sensitivity, specificity, and diagnostic yield (defined as the proportion of patients with true-positive ECG monitoring findings) of ECG monitoring in the identification of 7- and 30-day adverse and arrhythmic events according to monitoring duration. RESULTS Of 242 patients included in the study, 29 patients had 7-day serious outcomes. Ten additional patients had serious outcomes at 30 days. The overall sensitivity, specificity, and diagnostic yield of ECG monitoring in the identification of 7-day adverse events were 0.55 (95% confidence interval [CI] = 0.36 to 0.74], 0.93 (95% CI = 0.89 to 0.96), and 0.07 (95% CI = 0.04 to 0.10), respectively. The sensitivity, specificity, and diagnostic yield of >12-hour ECG monitoring in the identification of 7-day adverse events were 0.89 (95% CI = 0.65 to 0.99), 0.78 (95% CI = 0.67 to 0.87), and 0.18 (95% CI = 0.12 to 0.28), respectively. Similar results were observed for 30-day adverse events. The median (interquartile range) ECG monitoring time was 6.5 (6 to 15) hours. ECG monitoring findings were positive in 31 patients. CONCLUSIONS Although the overall diagnostic accuracy of ECG monitoring is fair, its sensitivity at >12 hours' duration is substantially higher. These results suggest that prolonged (>12 hours) monitoring is a safe alternative to hospital admission in the management of non-low-risk patients with syncope in the ED.
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Affiliation(s)
- Monica Solbiati
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico UOC Pronto Soccorso e Medicina d'Urgenza Milano
- Dipartimento di Scienze Cliniche e di Comunità Università degli Studi di Milano Milano
| | - Franca Dipaola
- Internal Medicine, Syncope Unit IRCCS Humanitas Research Hospital Humanitas University Rozzano
| | - Paolo Villa
- UOC Medicina d'Urgenza e Pronto Soccorso Ospedale Luigi Sacco Milano
| | - Sonia Seghezzi
- UOC Medicina d'Urgenza e Pronto Soccorso Ospedale Niguarda Milano Italy
| | - Ivo Casagranda
- Dipartimento di Emergenza ed Accettazione Azienda Ospedaliera “Santi Antonio e Biagio e C. Arrigo,” Alessandria
| | | | - Elisa Fiorini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico UOC Pronto Soccorso e Medicina d'Urgenza Milano
| | - Lorenzo Porta
- UOC Medicina d'Urgenza e Pronto Soccorso Ospedale Luigi Sacco Milano
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche “L. Sacco,” Università degli Studi di Milano Milano
| | - Antonio Voza
- Emergency Department IRCCS Humanitas Research Hospital Rozzano
| | - Franca Barbic
- Internal Medicine, Syncope Unit IRCCS Humanitas Research Hospital Humanitas University Rozzano
| | - Nicola Montano
- Dipartimento di Scienze Cliniche e di Comunità Università degli Studi di Milano Milano
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico UOC Medicina Generale–Immunologia e Allergologia Milano Italy
| | - Raffaello Furlan
- Internal Medicine, Syncope Unit IRCCS Humanitas Research Hospital Humanitas University Rozzano
| | - Giorgio Costantino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico UOC Pronto Soccorso e Medicina d'Urgenza Milano
- Dipartimento di Scienze Cliniche e di Comunità Università degli Studi di Milano Milano
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24
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Kashani P, Saberinia A. Management of multiple traumas in emergency medicine department: A review. J Family Med Prim Care 2019; 8:3789-3797. [PMID: 31879615 PMCID: PMC6924209 DOI: 10.4103/jfmpc.jfmpc_774_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/16/2019] [Accepted: 10/09/2019] [Indexed: 11/04/2022] Open
Abstract
One of the main causes of adults' disability during their working age is multiple trauma. The process of medical care of patients who are injured seriously is still a challenging job. The primary treatment of these patients in the emergency medicine departments is the most required choice after the wilderness first aid and also would be very required before definitive care in the hospital. The main aim of emergency medicine departments is quick recognition and treatment of injuries which pose severe threat to patients' life in appropriate order of priority. The procedure of primary evaluation in emergency medicine department with the help of medical routine examination and ultrasonography is based on the concept of focused assessment with sonography in trauma (FAST) for identifying spontaneous intraperitoneal hemorrhage. Emergency patients who suffer from massive hematothorax, serious lung and heart traumas, and penetrating traumas to the chest would undergo thoracotomy and patients who have few symptoms of perforated hollow viscous will undergo emergency laparotomy. Based on the trauma severity, emergency treatment could be the way to fast recovery of the structure of injured organ and its function. The subsequent goal, in the acute phase, will concentrate on preventing and stopping bleeding and secondary injuries like painful compartment syndrome or intra-abdominal infections (IAIs). However, the main aim of emergency medicine department in taking care of severely injured patients is the management of airway, protecting circulation and breathing, identification of neurologic problems, and whole body clinical examination with the help of healthcare providers.
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Affiliation(s)
- Parvin Kashani
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Loghman Hakim Hospital, Tehran, Iran
| | - Amin Saberinia
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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25
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Tavirani MR, Beigvand HH. A Review of Various Methods of Management of Risk in the Field of Emergency Medicine. Open Access Maced J Med Sci 2019; 7:4179-4187. [PMID: 32165973 PMCID: PMC7061389 DOI: 10.3889/oamjms.2019.616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 11/23/2019] [Accepted: 11/24/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND: The main concept of risk management in the emergency department (ED) contains a broader meaning, so that; it’s known as a sudden event or situation which would happen at an uncertain future that has some negative or positive impacts which could be called threat or opportunity respectively. However, the knowledge of risk management could cover the overall procedures involved with administering the planning of risk management, identification, investigation, monitoring and also step by step clinical examination. One of the main tools for preventing adversities is evaluating and management of possible risks. AIM: One of the main objectives of the present study is recognising the most frequent types of the risk happening in the EDs. Moreover, the present study is trying to evaluate the possible risks which could happen among various ED sections. METHODS: Six databases of EMBASE, HubMed, Cochrane Library, MEDLINE, PubMed, CHBD and Goggle scholar were chosen for discovering much-related articles from the year 2005 to 2019. A total number of 68 were chosen finally to be reviewed more precisely based on the main objective of the present study. RESULTS: Precise planning, preparing sufficiently and conducting the process of continuous monitoring are needed for ensuring the fact that any possible risks could be managed through these planned strategies. On the other hand, by modifying the patients’ beliefs, anticipations and the available social culture about the importance of risk management issue, the overall objective of the present study could be achieved at higher rates. CONCLUSION: Moreover, because the potential of occurrence of risk in EDs is high and approximately more than half of them are fatal, more precise adequate systematic plans for management of them should result.
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Affiliation(s)
- Majid Rezaei Tavirani
- Faculty of Medicine, Iran University of Medical Sciences, Firoozabadi Research Development Center, Tehran, Iran
| | - Hazhir Heidari Beigvand
- Faculty of Medicine, Iran University of Medical Sciences, Firoozabadi Research Development Center, Tehran, Iran
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26
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Long-term outcomes in syncope patients presenting to the emergency department: A systematic review. CAN J EMERG MED 2019; 22:45-55. [PMID: 31571558 DOI: 10.1017/cem.2019.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Long-term outcomes among syncope patients are not well studied to guide physicians regarding outpatient testing and follow-up. The objective of this study was to conduct a systematic review for outcomes at 1-year or later among ED syncope patients. METHODS We searched Cochrane Central, Medline, Medline in Process, PubMed, Embase, and the Cumulative Index to Nursing databases from inception to December 2018. We included studies that reported long-term outcomes among ED syncope patients. We excluded studies on patients <16 years old, studies that included syncope mimickers (pre-syncope, seizure, intoxication, loss of consciousness after head trauma), case reports, letters to the editor, non-English and review articles. Outcomes included death, syncope recurrence requiring hospitalization, arrhythmias and procedural interventions for arrhythmias. Meta-analysis was performed by pooling the outcomes using random effects model. RESULTS Initial literature search generated 2,094 articles duplicate removal. Of the 50 articles selected for full-text review, 19 articles with 98,211 patients were included in this review: of which 12 were included in the 1-year outcome meta-analysis. Pooled analysis showed : 7.0% mortality; 16.0% syncope recurrence requiring hospitalization; 6.0% with device insertion. 1-year arrhythmias reported in two studies were 1.1 and 26.4%. Pooled analysis for outcome at 31 to 365 days showed: 5.0% mortality and 1% device insertion. Two studies reported 4.9% and 21% mortality at 30 months and 4.2 years follow-up. CONCLUSIONS An important proportion of ED syncope patients suffer long-term morbidity and mortality. Appropriate follow-up is needed and future research to identify patients at risk is needed.
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27
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Thiruganasambandamoorthy V, Rowe BH, Sivilotti MLA, McRae AD, Arcot K, Nemnom MJ, Huang L, Mukarram M, Krahn AD, Wells GA, Taljaard M. Response by Thiruganasambandamoorthy et al to Letters Regarding Article, "Duration of Electrocardiographic Monitoring of Emergency Department Patients With Syncope". Circulation 2019; 140:e655-e656. [PMID: 31525105 DOI: 10.1161/circulationaha.119.041639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Departments of Emergency Medicine (V.T.), University of Ottawa, ON, Canada.,School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, ON, Canada.,Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Canada (B.H.R.)
| | - Marco L A Sivilotti
- Departments of Emergency Medicine (M.L.A.S.), Queen's University, Kingston, ON, Canada.,Biomedical and Molecular Sciences (M.L.A.S.), Queen's University, Kingston, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, AB, Canada (A.D.M.)
| | - Kirtana Arcot
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Marie-Joe Nemnom
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Longlong Huang
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Muhammad Mukarram
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada (A.D.K.)
| | - George A Wells
- School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, ON, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, ON, Canada.,Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
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28
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Zimmermann T, du Fay de Lavallaz J, Mueller C. Letter by Zimmermann et al Regarding Article, "Duration of Electrocardiographic Monitoring of Emergency Department Patients With Syncope". Circulation 2019; 140:e652-e653. [PMID: 31525102 DOI: 10.1161/circulationaha.119.040355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tobias Zimmermann
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (T.Z., J.d.F.d.L., C.M.).,Global Research on Acute Conditions Team Network, Rome, Italy (T.Z., J.d.F.d.L., C.M.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (T.Z., J.d.F.d.L., C.M.).,Global Research on Acute Conditions Team Network, Rome, Italy (T.Z., J.d.F.d.L., C.M.)
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (T.Z., J.d.F.d.L., C.M.).,Global Research on Acute Conditions Team Network, Rome, Italy (T.Z., J.d.F.d.L., C.M.)
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