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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Sun BC, Thiruganasambandamoorthy V, Cruz JD (2012) Consortium to standardize ED syncope risk stratification, reporting. standardized reporting guidelines for emergency department syncope risk-stratification research. Acad Emerg Med 19(6):694–702
Soteriades ES, Evans JC, Larson MG et al (2002) Incidence and prognosis of syncope. N Engl J Med 347(12):878–885
Colman N, Nahm K, Ganzeboom KS et al (2004) Epidemiology of reflex syncope. Clin Auton Res 14(Suppl 1):9–17
Sun BC, Emond JA, Camargo CA Jr (2004) Characteristics and admission patterns of patients presenting with syncope to U.S. emergency departments, 1992–2000. Acad Emerg Med 11(10):1029–1034
Kapoor WN (1990) Evaluation and outcome of patients with syncope. Medicine 69(3):160–175
Costantino G, Perego F, Dipaola F et al (2008) Short- and long-term prognosis of syncope, risk factors, and role of hospital admission: Results from the STePS (short-term prognosis of syncope) study. J Am Coll Cardiol 51(3):276–283
Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA (2004) Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes. Ann Emerg Med 43(2):224–232
Martin TP, Hanusa BH, Kapoor WN (1997) Risk stratification of patients with syncope. Ann Emerg Med 29(4):459–466
Thiruganasambandamoorthy V, Hess EP, Turko E, Perry JJ, Wells GA, Stiell IG (2013) Outcomes in Canadian emergency department syncope patients—are we doing a good job? J Emerg Med 44(2):321–328
Reed MJ, Newby DE, Coull AJ, Prescott RJ, Jacques KG, Gray AJ (2010) The ROSE (risk stratification of syncope in the emergency department) study. J Am Coll Cardiol 55(8):713–721
Thiruganasambandamoorthy V, Hess EP, Alreesi A, Perry JJ, Wells GA, Stiell IG (2010) External validation of the San Francisco syncope rule in the Canadian setting. Ann Emerg Med 55(5):464–472
Quinn J, McDermott D, Stiell I, Kohn M, Wells G (2006) Prospective validation of the San Francisco syncope rule to predict patients with serious outcomes. Ann Emerg Med 47(5):448–454
Grossman SA, Fischer C, Lipsitz LA et al (2007) Predicting adverse outcomes in syncope. J Emerg Med 33(3):233–239
Blanc JJ, L’Her C, Touiza A, Garo B, L’Her E, Mansourati J (2002) Prospective evaluation and outcome of patients admitted for syncope over a 1 year period. Eur Heart J 23(10):815–820
Cosgriff TM, Kelly AM, Kerr D (2007) External validation of the San Francisco syncope rule in the Australian context. CJEM Can J Emerg Med Care 9(3):157–161
Ben-Chetrit E, Flugelman M, Eliakim M (1985) Syncope: a retrospective study of 101 hospitalized patients. Isr J Med Sci 21(12):950–953
Quinn J, McDermott D (2007) External validation of the San Francisco syncope rule. Ann Emerg Med 50(6):742–743
Sun BC, Mangione CM, Merchant G et al (2007) External validation of the San Francisco syncope rule. Ann Emerg Med 49(4):420–427
Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ (2008) Failure to validate the San Francisco syncope rule in an independent emergency department population. Ann Emerg Med 52(2):151–159
Quinn JV, Stiell IG, McDermott DA, Kohn MA, Wells GA (2005) The San Francisco syncope rule vs physician judgment and decision making. Am J Emerg Med 23(6):782–786
Hoefnagels WA, Padberg GW, Overweg J, van der Velde EA, Roos RA (1991) Transient loss of consciousness: the value of the history for distinguishing seizure from syncope. J Neurol 238(1):39–43
Moya A, Sutton R, Ammirati F et al (2009) Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 30(21):2631–2671. doi:10.1093/eurheartj/ehp298. [Epub 2009 Aug 27 2009;30(12)]
Ammirati F, Colivicchi F, Santini M (2000) Diagnosing syncope in clinical practice. Implementation of a simplified diagnostic algorithm in a multicentre prospective trial—the OESIL 2 study (osservatorio epidemiologico della sincope nel lazio) [see comment]. Eur Heart J 21(11):935–940
Shen WK, Decker WW, Smars PA et al (2004) Syncope evaluation in the emergency department study (SEEDS): a multidisciplinary approach to syncope management. Circulation 110(24):3636–3645
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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The study was approved by the hospital research ethics boards at all the study sites.
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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:
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sustained (>30 s) or polymorphic ventricular tachycardia;
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sinus bradycardia <40 beats/min;
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sick sinus with alternating sinus bradycardia and tachycardia;
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sinus pause >3 s;
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Mobitz type II atrioventricular heart block;
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complete heart block or junctional/idioventricular rhythm;
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alternating left and right bundle branch block;
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symptomatic (light-headedness/dizziness, hypotension—systolic BP <90 mmHg) supraventricular tachycardia with rate >100/min;
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symptomatic atrial flutter or fibrillation with fast (>100/min) or slow (RR interval >3 s) ventricular rate;
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pacemaker or implantable cardioverter-defibrillator (ICD) malfunction with cardiac pauses, or
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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:
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aortic stenosis with valve area ≤1 cm2;
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hypertrophic cardiomyopathy with outflow tract obstruction;
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left atrial myxoma or thrombus with outflow tract obstruction; or
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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.
Appendix 3
See Table 5.
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