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Simos P, Scott I. Appropriate use of transthoracic echocardiography in the investigation of general medicine patients presenting with syncope or presyncope. Postgrad Med J 2022; 99:postgradmedj-2021-141416. [PMID: 35169024 DOI: 10.1136/postgradmedj-2021-141416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/22/2022] [Indexed: 01/03/2023]
Abstract
STUDY PURPOSE Routine transthoracic echocardiography (TTE) in patients with syncope or presyncope is resource-intensive. We assessed if risk thresholds defined by a validated risk score may identify patients at low risk of cardiac abnormality in whom TTE is unnecessary. STUDY DESIGN We conducted a retrospective study of all general medicine patients with syncope/presyncope presenting to a tertiary hospital between July 2016 and September 2020 and who underwent TTE. The Canadian Syncope Risk Score (CSRS) was used to categorise patients as low to very low risk (score -3 to 0) or moderate to high risk (score ≥1) for serious adverse events at 30 days. A cut-point of 0 was used to calculate the sensitivity, specificity, positive and negative predictive values (PPV and NPV) for CSRS and the odds ratio (OR) of a clinically significant finding on TTE in patients with CSRS ≥1 compared with all patients. RESULTS Among 157 patients, the CSRS categorised 69 (44%) as very low to low risk in whom TTE was normal. In 88 patients deemed moderate to high risk, TTE detected a cardiac abnormality in 24 (27%). A CSRS ≥1 yielded a sensitivity of 100% (95% CI 85.7% to 100%), specificity of 51.1% (95% CI 42.3% to 59.8%), PPV of 26.5% (95% CI 26.3% to 30.1%) and NPV of 100% (95% CI 92.5% to 100%) for cardiac abnormalities and doubled the odds of an abnormality (OR=2.05, 95% CI 1.08 to 3.87, p=0.028). CONCLUSION In general medicine patients with syncope/presyncope, using the CSRS to stratify risk of a cardiac abnormality on TTE can almost halve TTE use.
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Affiliation(s)
- Peter Simos
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia .,School of Clinical Medicine, University of Queensland Faculty of Health and Behavioural Sciences, Herston, Queensland, Australia
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Abstract
ABSTRACT Syncope is a common medical presentation that can cost the US healthcare system up to $2.4 billion dollars annually. Much of this cost can be mitigated with proper evaluation and management in the urgent care setting, as well as appropriate use of a risk stratification system.
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Affiliation(s)
- Brandon Geer
- Brandon Geer is an urgent care NP at United Memorial Medical Center Urgent Care, Batavia, N.Y
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Kligerman SJ, Bykowski J, Hurwitz Koweek LM, Policeni B, Ghoshhajra BB, Brown MD, Davis AM, Dibble EH, Johnson TV, Khosa F, Ledbetter LN, Leung SW, Liebeskind DS, Litmanovich D, Maroules CD, Pannell JS, Powers WJ, Villines TC, Wang LL, Wann S, Corey AS, Abbara S. ACR Appropriateness Criteria® Syncope. J Am Coll Radiol 2021; 18:S229-S238. [PMID: 33958116 DOI: 10.1016/j.jacr.2021.02.021] [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] [Received: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
Syncope and presyncope lead to well over one million emergency room visits in the United States each year. Elucidating the cause of syncope or presyncope, which are grouped together given similar etiologies and outcomes, can be exceedingly difficult given the diverse etiologies. This becomes more challenging as some causes, such as vasovagal syncope, are relatively innocuous while others, such as cardiac-related syncope, carry a significant increased risk of death. While the mainstay of syncope and presyncope assessment is a detailed history and physical examination, imaging can play a role in certain situations. In patients where a cardiovascular etiology is suspected based on the appropriate history, physical examination, and ECG findings, resting transthoracic echocardiography is usually considered appropriate for the initial imaging. While no imaging studies are considered usually appropriate when there is a low probability of cardiac or neurologic pathology, chest radiography may be appropriate in certain clinical situations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Julie Bykowski
- University of California San Diego, San Diego, California
| | | | - Bruno Policeni
- Panel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Michael D Brown
- Michigan State University, East Lansing, Michigan, American College of Emergency Physicians
| | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois, American College of Physicians
| | | | - Thomas V Johnson
- Sanger Heart and Vascular Institute, Charlotte, North Carolina, Cardiology expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Steve W Leung
- Gill Heart & Vascular Institute, University of Kentucky, Lexington, Kentucky, Society for Cardiovascular Magnetic Resonance, Program Director, Advanced Cardiovascular Imaging Fellowship, Director of Cardiac MRI, University of Kentucky
| | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California, American Academy of Neurology
| | - Diana Litmanovich
- Harvard Medical School, Boston, Massachusetts, Section Chief, Cardiothoracic, Department of Radiology, Beth Israel Deaconess Medical Center, President, North American Society for Cardiovascular Imaging, Co-Chair, Image Wisely
| | | | | | - William J Powers
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, American Academy of Neurology
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia, Society of Cardiovascular Computed Tomography
| | - Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio, Program Director, Neuroradiology Fellowship, University of Cincinnati
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin, Nuclear cardiology expert
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas, Chief, Cardiothoracic Imaging, UT Southwestern, Member BOD, SCCT, Editor, Radiology - Cardiothoracic Imaging
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Probst MA, Gibson TA, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Hollander JE, Nicks BA, Nishijima DK, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Predictors of Clinically Significant Echocardiography Findings in Older Adults with Syncope: A Secondary Analysis. J Hosp Med 2018; 13:823-828. [PMID: 30255862 PMCID: PMC6343846 DOI: 10.12788/jhm.3082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Syncope is a common reason for visiting the emergency department (ED) and is associated with significant healthcare resource utilization. OBJECTIVE To develop a risk-stratification tool for clinically significant findings on echocardiography among older adults presenting to the ED with syncope or nearsyncope. DESIGN Prospective, observational cohort study from April 2013 to September 2016. SETTING Eleven EDs in the United States. PATIENTS We enrolled adults (=60 years) who presented to the ED with syncope or near-syncope who underwent transthoracic echocardiography (TTE). MEASUREMENTS The primary outcome was a clinically significant finding on TTE. Clinical, electrocardiogram, and laboratory variables were also collected. Multivariable logistic regression analysis was used to identify predictors of significant findings on echocardiography. RESULTS A total of 3,686 patients were enrolled. Of these, 995 (27%) received echocardiography, and 215 (22%) had a significant finding on echocardiography. Regression analysis identified five predictors of significant finding: (1) history of congestive heart failure, (2) history of coronary artery disease, (3) abnormal electrocardiogram, (4) high-sensitivity troponin-T >14 pg/mL, and 5) N-terminal pro B-type natriuretic peptide >125 pg/mL. These five variables make up the ROMEO (Risk Of Major Echocardiography findings in Older adults with syncope) criteria. The sensitivity of a ROMEO score of zero for excluding significant findings on echocardiography was 99.5% (95% CI: 97.4%-99.9%) with a specificity of 15.4% (95% CI: 13.0%-18.1%). CONCLUSIONS If validated, this risk-stratification tool could help clinicians determine which syncope patients are at very low risk of having clinically significant findings on echocardiography. REGISTRATION ClinicalTrials.gov Identifier NCT01802398.
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Affiliation(s)
- Marc A. Probst
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Tommy A. Gibson
- Department of Biostatistics, University of California, Los Angeles, CA, USA
| | - Robert E. Weiss
- Department of Biostatistics, University of California, Los Angeles, CA, USA
| | - Annick N. Yagapen
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Heath & Science University, Portland, OR, USA
| | - Susan E. Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Heath & Science University, Portland, OR, USA
| | | | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital-Troy, Troy, MI, USA
| | | | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carol L. Clark
- Department of Emergency Medicine, William Beaumont Hospital-Royal Oak, Royal Oak, MI, USA
| | - Deborah B. Diercks
- Department of Emergency Medicine, University of Texas-Southwestern, Dallas, TX, USA, USA
| | - Judd E. Hollander
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Bret A. Nicks
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, N, USA
| | - Daniel K. Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, USA
| | - Manish N. Shah
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Kirk A. Stiffler
- Department of Emergency Medicine, Northeastern Ohio Medical University, Rootstown, OH, USA
| | - Alan B. Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, USA
| | - Scott T. Wilber
- Department of Emergency Medicine, Northeastern Ohio Medical University, Rootstown, OH, USA
| | - Benjamin C. Sun
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Heath & Science University, Portland, OR, USA
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Baugh CW, Sun BC. Variation in diagnostic testing for older patients with syncope in the emergency department. Am J Emerg Med 2018; 37:810-816. [PMID: 30054114 DOI: 10.1016/j.ajem.2018.07.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/21/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Older adults presenting with syncope often undergo intensive diagnostic testing with unclear benefit. We determined the variation, frequency, yield, and costs of tests obtained to evaluate older persons with syncope. METHODS We conducted a prospective, multicenter observational cohort study in 11 academic emergency departments in the United States of 3686 patients aged ≥60 years presenting with syncope or presyncope. We measured the frequency, variation, yield, and costs (based on Medicare payment tables) of diagnostic tests performed at the index visit. RESULTS While most study rates were similar across sites, some were notably discordant (e.g., carotid ultrasound: mean 9.5%, range 1.1% to 49.3%). The most frequently-obtained diagnostic tests were initial troponin (88.6%), chest x-ray (75.1%), head CT (42.5%) and echocardiogram (35.5%). The yield or proportion of abnormal findings by diagnostic test ranged from 1.9% (electrocardiogram) to 42.0% (coronary angiography). Among the most common tests, echocardiogram had the highest proportion of abnormal results at 22.1%. Echocardiogram was an outlier in total cost at $672,648, and had a cost per abnormal test of $3129. CONCLUSION Variation in diagnostic testing in older patients presenting with syncope exists. The yield and cost per abnormal result for common tests obtained to evaluate syncope are also highly variable. Selecting tests based on history and examination while also prioritizing less resource intensive and higher yield tests may ensure a more informed and cost-effective approach to evaluating older patients with syncope.
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Affiliation(s)
- Christopher W Baugh
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA, United States of America.
| | - Benjamin C Sun
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Heath & Science University, Portland, OR, United States of America
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