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Emergency department management of syncope: need for standardization and improved risk stratification

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Abstract

Variations in emergency department (ED) syncope management have not been well studied. The goals of this study were to assess variations in management, and emergency physicians’ risk perception and disposition decision making. We conducted a prospective study of adults with syncope in six EDs in four cities over 32 months. We collected patient characteristics, ED management, disposition, physicians’ prediction probabilities at index presentation and followed patients for 30 days for serious outcomes: death, myocardial infarction (MI), arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, or procedural interventions. We used descriptive statistics, ROC curves, and regression analyses. We enrolled 3662 patients: mean age 54.3 years, and 12.9 % were hospitalized. Follow-up data were available for 3365 patients (91.9 %) and 345 patients (10.3 %) suffered serious outcomes: 120 (3.6 %) after ED disposition including 48 patients outside the hospital. After accounting for differences in patient case mix, the rates of ED investigations and disposition were significantly different (p < 0.0001) across the four study cities; as were the rates of 30-day serious outcomes (p < 0.0001) and serious outcomes after ED disposition (p = 0.0227). There was poor agreement between physician risk perception and both observed event rates and referral patterns (p < 0.0001). Only 76.7 % (95 % CI 68.1–83.6) of patients with serious outcomes were appropriately referred. There are large and unexplained differences in ED syncope management. Moreover, there is poor agreement between physician risk perception, disposition decision making, and serious outcomes after ED disposition. A valid risk-stratification tool might help standardize ED management and improve disposition decision making.

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Acknowledgments

We acknowledge members of our research team: Pam Ladouceur RN, Mackenzie Eaton RN, Sarah Gaudet RN, Karen Pratt RN, Dr. Muhammad Mukarram MBBS, MPH, Natacha Leduc, Soo-Min Kim BScH, Cynthia Campbell, Marco Guarino, My-Linh Tran, Sheryl Domingo, Catherine Clement RN and Angela Marcantonio for their help. Funding: this study was funded by grants from the Physicians Services Incorporated Foundation and the Canadian Institutes of Health Research. Dr. Thiruganasambandamoorthy was supported by Heart and Stroke Foundation of Canada through the Jump Start Resuscitation Scholarship.

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Ethical standard

The study was approved by the hospital research ethics boards at all the study sites.

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Correspondence to Venkatesh Thiruganasambandamoorthy.

Appendices

Appendix 1: definitions for outcome measures

The list of serious outcome measures collected and their definitions are detailed below:

a) Death related to a cause of syncope or due to unknown causes;

b) Arrhythmias:

  • sustained (>30 s) or polymorphic ventricular tachycardia;

  • sinus bradycardia <40 beats/min;

  • sick sinus with alternating sinus bradycardia and tachycardia;

  • sinus pause >3 s;

  • Mobitz type II atrioventricular heart block;

  • complete heart block or junctional/idioventricular rhythm;

  • alternating left and right bundle branch block;

  • symptomatic (light-headedness/dizziness, hypotension—systolic BP <90 mmHg) supraventricular tachycardia with rate >100/min;

  • symptomatic atrial flutter or fibrillation with fast (>100/min) or slow (RR interval >3 s) ventricular rate;

  • pacemaker or implantable cardioverter-defibrillator (ICD) malfunction with cardiac pauses, or

  • an abnormal electrophysiological study (corrected sinus node recovery time >550 ms; his-ventricular intervals >100 ms; inducible ventricular tachycardia for >30 s; polymorphic ventricular tachycardia/ventricular fibrillation in patients with Brugada or ventricular dysplasia or previous cardiac arrest; symptomatic supraventricular tachycardia, or infra-Hisian block);

c) Myocardial infarction: defined as a clinically important elevation in troponin or ECG change and must have been confirmed by the emergency physician or cardiologist or the most responsible physician;

d) Serious structural heart disease:

  • aortic stenosis with valve area ≤1 cm2;

  • hypertrophic cardiomyopathy with outflow tract obstruction;

  • left atrial myxoma or thrombus with outflow tract obstruction; or

  • pericardial effusion with ventricular wall motion abnormalities or pericardial tamponade;

e) Aortic dissection—confirmed by computerized tomography of the chest, trans-esophageal echocardiogram, MRI or angiography;

f) Pulmonary embolism—confirmed by ventilation-perfusion (VQ) scan, computed tomography scan of the chest or angiography;

g) Severe pulmonary artery hypertension—detected by cardiac catheterization or echocardiography with a mean pulmonary arterial pressure >30 mmHg and was responsible for the syncope;

h) Subarachnoid hemorrhage—confirmed by computed tomography/magnetic resonance imaging of the brain with or without spinal fluid analysis by lumbar puncture;

i) Significant hemorrhage—defined as syncope associated with detected source of bleeding such as gastrointestinal bleeding, ruptured abdominal aortic aneurysm, or ectopic pregnancy that is clinically significant to cause syncope in the opinion of the treating physician or that required transfusion;

j) Any other serious condition: includes conditions such as ectopic pregnancy, pneumothorax, sepsis that will require treatment and will cause the patient to return to the emergency department if not detected;

k) Procedural interventions—any interventions used to treat a cause of syncope. The procedural interventions include pacemaker and/or defibrillator insertion, cardioversion for arrhythmias, surgery for valvular heart disease, dialysis for electrolyte abnormalities causing arrhythmia, chest tube/pig tail catheter insertion for pneumothorax or pleural effusion, or surgery for abdominal aortic aneurysm or ruptured spleen.

Appendix 2

See Table 4.

Table 4 Characteristics of 1062 potentially eligible syncope patients not enrolled in the study

Appendix 3

See Table 5.

Table 5 Characteristics of 297 study patients lost to follow-up

Appendix 4: timing of occurrence of 30 day serious outcomes among syncope patients after emergency department disposition

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Thiruganasambandamoorthy, V., Taljaard, M., Stiell, I.G. et al. Emergency department management of syncope: need for standardization and improved risk stratification. Intern Emerg Med 10, 619–627 (2015). https://doi.org/10.1007/s11739-015-1237-1

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  • DOI: https://doi.org/10.1007/s11739-015-1237-1

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