51
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Affiliation(s)
- Josh Waytz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
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52
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Numeroso F, Mossini G, Lippi G, Cervellin G. Syncope: current knowledge, uncertainties and strategies for management optimisation in the emergency department. Acta Cardiol 2018; 73:215-221. [PMID: 28799452 DOI: 10.1080/00015385.2017.1362146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Admission rates and expenditures for syncope remain high. This unsatisfactory management could be due to several factors, including lack of evidence-based strategy, poor accuracy of clinical decision rules, difficulty in disseminating guidelines, as well as uncertainties concerning management of intermediate-risk patients and role of observation protocols and syncope units. To optimise management, it has been proposed to adopt a pragmatic, symptoms-based definition of syncope and a classification related to the underlying mechanism rather than suspected aetiology. It has also been emphasised the importance of identifying patients at intermediate risk as they can be safely discharged after an intensive emergency department evaluation. A further improvement might result from a research implementation to validate the role of observation protocols and to select patients amenable to be sent to outpatient syncope units. Finally, future studies on prognostic significance of syncope should be performed with a more careful selection of outcomes and a greater uniformity.
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Affiliation(s)
- Filippo Numeroso
- Department of Emergency, Academic Hospital of Parma, Parma, Italy
| | | | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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53
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Gehi AK, Narla V. Syncope: Laying the Groundwork for a Path Forward. JACC Clin Electrophysiol 2018; 4:274-276. [PMID: 29749949 DOI: 10.1016/j.jacep.2017.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Anil K Gehi
- Division of Cardiology, Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina.
| | - Venkata Narla
- Division of Cardiology, Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
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54
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Anand V, Benditt DG, Adkisson WO, Garg S, George SA, Adabag S. Trends of hospitalizations for syncope/collapse in the United States from 2004 to 2013-An analysis of national inpatient sample. J Cardiovasc Electrophysiol 2018; 29:916-922. [PMID: 29505697 DOI: 10.1111/jce.13479] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/09/2018] [Accepted: 02/23/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Syncope/collapse is a common reason for emergency department visits, and approximately 30-40% of these individuals are hospitalized. We examined changes in hospitalization rates, in-hospital mortality, and cost of syncope/collapse-related hospital care in the United States from 2004 to 2013. METHODS We used the US Nationwide Inpatient Sample (NIS) from 2004 to 2013 to identify syncope/collapse-related hospitalizations using ICD-9, code 780.2, as the principal discharge diagnosis. Data are presented as mean ± SEM. RESULTS From 2004 to 2013, there was a 42% reduction in hospitalizations with a principal discharge diagnosis of syncope/collapse from 54,259 (national estimate 253,591) in 2004 to 31,427 (national estimate 156,820) in 2013 (P < 0.0001). The mean length of hospital stays decreased (2.88 ± 0.04 days in 2004 vs. 2.54 ± 0.02 in 2013; P < 0.0001), while in-hospital mortality did not change (0.28% in 2004 vs. 0.18% in 2013; P = 0.12). However, mean charges (inflation adjusted) for syncope/collapse-related hospitalization increased by 43.6% from $17,514 in 2004 to $25,160 in 2013 (P < 0.0001). The rates of implantation of permanent pacemakers and implantable cardioverter defibrillator remained low during these hospitalizations, and decreased over time (P for both < 0.0001). CONCLUSIONS Hospitalization rates for syncope/collapse have decreased significantly in the US from 2004 to 2013. Despite a modest reduction in length of stay, the cost of syncope/collapse-related hospital care has increased.
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Affiliation(s)
- Vidhu Anand
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - David G Benditt
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Wayne O Adkisson
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Sushil Garg
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Stephen A George
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Selcuk Adabag
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.,Division of Cardiology, Department of Medicine, Minneapolis VA Healthcare System, Minneapolis, MN, USA
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55
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 993] [Impact Index Per Article: 165.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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56
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Bacellar A, Assis T, Pedreira BB, Costa G, Nascimento OJM. Hospital Mortality Among Elderly Patients Admitted With Neurological Disorders Was Not Predicted by any Particular Diagnosis in a Tertiary Medical Center. Open Neurol J 2018; 12:1-11. [PMID: 29456768 PMCID: PMC5806177 DOI: 10.2174/1874205x01812010001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/19/2017] [Accepted: 12/30/2017] [Indexed: 11/25/2022] Open
Abstract
Background: Neurological disorders (NDs) are associated with high hospital mortality. We aimed to identify predictors of hospital mortality among elderly inpatients with NDs. Methods: Patients aged ≥60 years admitted to the hospital between January 1, 2009 and December 31, 2010 with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic data, NDs, and comorbidities as independent predictors of hospital mortality. Logistic regression was performed for multivariable analysis. Results: Overall, 1540 NDs and 2679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8±9.1). Of these, 54.5% were female. Diagnostic frequency of NDs ranged between 0.3% and 50.8%. Diagnostic frequency of comorbidities ranged from 5.6% to 84.5%. Comorbidities varied from 0 to 9 per patient (90% of patients had ≥2 comorbidities), mean 3.2±1.47(CI, 3.1-3.3). Patients with multimorbidities presented with a mean of 4.7±1.7 morbidities per patient. Each ND and comorbidity were associated with high hospital mortality, producing narrow ranges between the lowest and highest incidences of death (hospital mortality = 18%) (95% CI, 15%-21%). After multivariable analysis, advanced age (P<0.001) and low socioeconomic status (P=0.003) were recognized as predictors of mortality, totaling 9% of the variables associated with hospital mortality. Conclusion: Neither a particular ND nor an individual comorbidity predicted hospital mortality. Age and low socioeconomic class accounted for 9% of predictors. We suggest evaluating whether functional, cognitive, or comorbidity scores will improve the risk model of hospital mortality in elderly patients admitted with ND.
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Affiliation(s)
- Aroldo Bacellar
- Hospital Sao Rafael, Department of Neurology Av Sao Rafael 2152, Sao Marcos, Salvador, BA, CEP 41235-190, Brazil
| | - Telma Assis
- Hospital Sao Rafael, Department of Neurology Av Sao Rafael 2152, Sao Marcos, Salvador, BA, CEP 41235-190, Brazil
| | - Bruno B Pedreira
- Hospital Sao Rafael, Department of Neurology Av Sao Rafael 2152, Sao Marcos, Salvador, BA, CEP 41235-190, Brazil
| | - Gersonita Costa
- Hospital Sao Rafael, Department of Neurology Av Sao Rafael 2152, Sao Marcos, Salvador, BA, CEP 41235-190, Brazil
| | - Osvaldo J M Nascimento
- Hospital Sao Rafael, Department of Neurology Av Sao Rafael 2152, Sao Marcos, Salvador, BA, CEP 41235-190, Brazil
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57
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Numeroso F, Mossini G, Lippi G, Cervellin G. Role of emergency department observation units in the management of patients with unexplained syncope: a critical review and meta-analysis. Clin Exp Emerg Med 2017; 4:201-207. [PMID: 29306267 PMCID: PMC5758624 DOI: 10.15441/ceem.17.231] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/08/2017] [Accepted: 05/08/2017] [Indexed: 12/12/2022] Open
Abstract
This meta-analysis aimed to establish the role of standardized emergency department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission. A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units. Data regarding mean length of stay, rate of etiological diagnosis, admission rate, and incidence of short-term serious outcomes were extracted. Six mostly single-center, small sized studies characterized by high heterogeneity, were included. A total of 458 patients were included with a balanced sex distribution (male 50.2%), a mean age of 60.1 years, and a considerable prevalence of heart disease (32.4%). Pooled analysis of the outcomes showed a mean stay of 28.2 hours, an etiological diagnosis rate of 67.3%, an admission rate of 18.5%, and a very low incidence of short-term serious outcomes (2.8%). Due to elevated diagnostic yield and low incidence of short-term adverse events, ED observation units-based management strategy seems ideal for patients with syncope. Nevertheless, further research is needed to identify criteria for selecting patients to be managed with this approach, define evaluation protocols, and confirm the safety of this strategy.
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Affiliation(s)
| | | | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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58
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Badertscher P, Nestelberger T, de Lavallaz JDF, Than M, Morawiec B, Kawecki D, Miró Ò, López B, Martin-Sanchez FJ, Bustamante J, Geigy N, Christ M, Di Somma S, Peacock WF, Cullen L, Sarasin F, Flores D, Tschuck M, Boeddinghaus J, Twerenbold R, Wildi K, Sabti Z, Puelacher C, Rubini Giménez M, Kozhuharov N, Shrestha S, Strebel I, Rentsch K, Keller DI, Poepping I, Buser A, Kloos W, Lohrmann J, Kuehne M, Osswald S, Reichlin T, Mueller C. Prohormones in the Early Diagnosis of Cardiac Syncope. J Am Heart Assoc 2017; 6:JAHA.117.006592. [PMID: 29426039 PMCID: PMC5779001 DOI: 10.1161/jaha.117.006592] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background The early detection of cardiac syncope is challenging. We aimed to evaluate the diagnostic value of 4 novel prohormones, quantifying different neurohumoral pathways, possibly involved in the pathophysiological features of cardiac syncope: midregional–pro‐A‐type natriuretic peptide (MRproANP), C‐terminal proendothelin 1, copeptin, and midregional‐proadrenomedullin. Methods and Results We prospectively enrolled unselected patients presenting with syncope to the emergency department (ED) in a diagnostic multicenter study. ED probability of cardiac syncope was quantified by the treating ED physician using a visual analogue scale. Prohormones were measured in a blinded manner. Two independent cardiologists adjudicated the final diagnosis on the basis of all clinical information, including 1‐year follow‐up. Among 689 patients, cardiac syncope was the adjudicated final diagnosis in 125 (18%). Plasma concentrations of MRproANP, C‐terminal proendothelin 1, copeptin, and midregional‐proadrenomedullin were all significantly higher in patients with cardiac syncope compared with patients with other causes (P<0.001). The diagnostic accuracies for cardiac syncope, as quantified by the area under the curve, were 0.80 (95% confidence interval [CI], 0.76–0.84), 0.69 (95% CI, 0.64–0.74), 0.58 (95% CI, 0.52–0.63), and 0.68 (95% CI, 0.63–0.73), respectively. In conjunction with the ED probability (0.86; 95% CI, 0.82–0.90), MRproANP, but not the other prohormone, improved the area under the curve to 0.90 (95% CI, 0.87–0.93), which was significantly higher than for the ED probability alone (P=0.003). An algorithm to rule out cardiac syncope combining an MRproANP level of <77 pmol/L and an ED probability of <20% had a sensitivity and a negative predictive value of 99%. Conclusions The use of MRproANP significantly improves the early detection of cardiac syncope among unselected patients presenting to the ED with syncope. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01548352.
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Affiliation(s)
- Patrick Badertscher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Martin Than
- GREAT Network, Rome, Italy.,Christchurch Hospital, Christchurch, New Zealand
| | - Beata Morawiec
- GREAT Network, Rome, Italy.,2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Damian Kawecki
- GREAT Network, Rome, Italy.,2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Òscar Miró
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Beatriz López
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
| | - José Bustamante
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Nicolas Geigy
- Department of Emergency Medicine, Hospital of Liestal, Switzerland
| | - Michael Christ
- GREAT Network, Rome, Italy.,Department of Emergency Care, Lucerne General Hospital, Lucerne, Switzerland
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy.,Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, Sant'Andrea Hospital University Sapienza Rome, Rome, Italy
| | - W Frank Peacock
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Louise Cullen
- GREAT Network, Rome, Italy.,Royal Brisbane and Women's Hospital, Herston, Australia
| | - François Sarasin
- Emergency Department, Hôpitaux Universitaires de Genève, Switzerland
| | - Dayana Flores
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Michael Tschuck
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Karin Wildi
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Zaid Sabti
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Christian Puelacher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Ivo Strebel
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Katharina Rentsch
- Laboratory Medicine, University Hospital Basel University of Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Imke Poepping
- Department of Internal Medicine, Hospital of Lachen, Switzerland
| | - Andreas Buser
- Department of Hematology, University Hospital Basel University of Basel, Switzerland.,Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland
| | - Michael Kuehne
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland .,GREAT Network, Rome, Italy
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Prognosis of patients with syncope seen in the emergency room department: an evaluation of four different risk scores recommended by the European Society of Cardiology guidelines. Eur J Emerg Med 2017; 24:428-434. [DOI: 10.1097/mej.0000000000000392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sandhu RK, Tran DT, Sheldon RS, Kaul P. A Population-Based Cohort Study Evaluating Outcomes and Costs for Syncope Presentations to the Emergency Department. JACC Clin Electrophysiol 2017; 4:265-273. [PMID: 29749948 DOI: 10.1016/j.jacep.2017.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/30/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study sought to examine outcomes and costs of patients with syncope admitted and discharged from the emergency department (ED). BACKGROUND ED visits for syncope are common, yet the impact on health care utilization is relatively unknown. METHODS A total of 51,831 consecutive patients presented to the ED with a primary diagnosis of syncope (International Classification of Diseases-9 code 780.2 and International Classification of Diseases-10 code R55) in Alberta, Canada from 2006 to 2014. Outcomes included 30-day syncope ED and hospital readmissions; 30-day and 1-year mortality; and annual inpatient, outpatient, physician, and drug costs, cumulative. RESULTS Of adults presenting to the ED, 6.6% were hospitalized and discharged with a primary diagnosis of syncope (Cohort 1), 8.7% were hospitalized and discharged with a primary diagnosis other than syncope (Cohort 2), and 84.7% were discharged home with a syncope diagnosis (Cohort 3). The 30-day ED revisits for syncope varied from 1.2% (Cohort 2) to 2.4% (Cohort 1) (p < 0.001), and readmission rates were <1% among cohorts. Short- and long-term mortality rates were highest for Cohort 2 and lowest for Cohort 3 (30-day mortality: Cohort 1 of 1.2%, Cohort 2 of 5.2%, Cohort 3 of 0.4%; p < 0.001) (1-year mortality: Cohort 1 of 9.2%, Cohort 2 of 17.7%, Cohort 3 of 3.0%; p < 0.001). Total cost of syncope presentations was $530.6 million (Cohort 1: $75.3 million; $29,519/patient, Cohort 2: $138.1 million; $42,042/patient, Cohort 3: $317.3 million; $9,963/patient; p<0.001). CONCLUSIONS Most patients with syncope presenting to the ED were discharged and had a favorable prognosis but overall costs were high compared with patients hospitalized. Further research is needed for cost-saving strategies across all cohorts.
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Affiliation(s)
- Roopinder K Sandhu
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.
| | - Dat T Tran
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert S Sheldon
- Division of Cardiology, University of Calgary, Calgary, Alberta, Canada
| | - Padma Kaul
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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Thiruganasambandamoorthy V, Stiell IG, Sivilotti MLA, Rowe BH, Mukarram M, Arcot K, Kwong K, McRae AD, Wells GA, Taljaard M. Predicting Short-term Risk of Arrhythmia among Patients With Syncope: The Canadian Syncope Arrhythmia Risk Score. Acad Emerg Med 2017; 24:1315-1326. [PMID: 28791782 DOI: 10.1111/acem.13275] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/31/2017] [Accepted: 08/04/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Syncope can be caused by serious occult arrhythmias not evident during initial emergency department (ED) evaluation. We sought to develop a risk tool for predicting 30-day arrhythmia or death after ED disposition. METHODS We conducted a multicenter prospective cohort study at six tertiary care EDs and included adults (≥16 years) with syncope. We collected standardized variables from clinical evaluation and investigations including electrocardiogram and troponin at index presentation. Adjudicated outcomes included death or arrhythmias including procedural interventions for arrhythmia within 30 days. We used multivariable logistic regression to derive the prediction model and bootstrapping for interval validation to estimate shrinkage and optimism. RESULTS A total of 5,010 patients (mean ± SD age = 53.4 ± 23.0 years, 54.8% females, and 9.5% hospitalized) were enrolled with 106 (2.1%) patients suffering 30-day arrhythmia/death after ED disposition. We examined 39 variables and eight were included in the final model: lack of vasovagal predisposition, heart disease, any ED systolic blood pressure < 90 or > 180 mm Hg, troponin (>99th percentile), QRS duration > 130 msec, QTc interval > 480 msec, and ED diagnosis of cardiac/vasovagal syncope (optimism corrected C-statistic 0.90 [95% CI = 0.87-0.93]; Hosmer-Lemeshow p = 0.08). The Canadian Syncope Arrhythmia Risk Score had a risk ranging from 0.2% to 74.5% for scores of -2 to 8. At a threshold score of ≥0, the sensitivity was 97.1% (95% CI = 91.6%-99.4%) and specificity was 53.4% (95% CI = 52.0%-54.9%). CONCLUSIONS The Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at risk for arrhythmias and aid in acute management decisions. Once validated, the score can identify low-risk patients who will require no further investigations.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine; University of Ottawa; Ottawa ON
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
| | - Ian G. Stiell
- Department of Emergency Medicine; University of Ottawa; Ottawa ON
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
| | - Marco L. A. Sivilotti
- Department of Emergency Medicine; Queen's University; Kingston ON
- Department of Biomedical and Molecular Sciences; Queen's University; Kingston ON
| | - Brian H. Rowe
- Department of Emergency Medicine and School of Public Health; Edmonton AB
| | | | - Kirtana Arcot
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
| | - Kenneth Kwong
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
| | - Andrew D. McRae
- Department of Emergency Medicine; University of Calgary; Calgary AB Canada
| | - George A. Wells
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
| | - Monica Taljaard
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
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Conley J, Bohan JS, Baugh CW. The Establishment and Management of an Observation Unit. Emerg Med Clin North Am 2017; 35:519-533. [PMID: 28711122 DOI: 10.1016/j.emc.2017.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The current health care landscape and evidence support the establishment of observation units (OUs) for safe and efficient care for observation patients. Careful attention is required in the design of OU process, location, and layout to enable optimal care and finances. Developing and maintaining protocols to guide patient selection and clinical care are critical. OU management requires a strong, collaborative leadership model, appropriate staffing, and a robust monitoring system for quality, safety, and finances. With a better understanding of these principles of OU establishment and management, hospital leaders can generate and sustain service excellence.
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Affiliation(s)
- Jared Conley
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - J Stephen Bohan
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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Ross MA, Granovsky M. History, Principles, and Policies of Observation Medicine. Emerg Med Clin North Am 2017; 35:503-518. [DOI: 10.1016/j.emc.2017.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: Executive summary. Heart Rhythm 2017; 14:e218-e254. [DOI: 10.1016/j.hrthm.2017.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 01/05/2023]
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Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain. Emerg Med Clin North Am 2017; 35:549-569. [PMID: 28711124 DOI: 10.1016/j.emc.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country.
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Abstract
For the diagnosis of reflex syncope, diligent history-building with the patient and a witness is required. In the Emergency Department (ED), the assessment of syncope is a challenge which may be addressed by an ED Observation Unit or by a referral to a Syncope Unit. Hospital admission is necessary for those with life-threatening cardiac conditions although risk stratification remains an unsolved problem. Other patients may be investigated with less urgency by carotid sinus massage (>40 years), tilt testing, and electrocardiogram loop recorder insertion resulting in a clear cause for syncope. Management includes, in general terms, patient education, avoidance of circumstances in which syncope is likely, increase in fluid and salt consumption, and physical counter-pressure maneuvers. In older patients, those that will benefit from cardiac pacing are now well defined. In all patients, the benefit of drug therapy is often disappointing and there remains no ideal drug. A role for catheter ablation may emerge for the highly symptomatic reflex syncope patient.
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2017; 14:e155-e217. [PMID: 28286247 DOI: 10.1016/j.hrthm.2017.03.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 12/26/2022]
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017; 70:620-663. [PMID: 28286222 DOI: 10.1016/j.jacc.2017.03.002] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e25-e59. [PMID: 28280232 DOI: 10.1161/cir.0000000000000498] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison.,Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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Numeroso F, Mossini G, Giovanelli M, Lippi G, Cervellin G. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk: Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med 2016; 23:941-8. [PMID: 27178670 DOI: 10.1111/acem.13013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 04/04/2016] [Accepted: 05/04/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Despite guidelines, admission rates and expenditures for syncope remain high. This may be caused by an imprecise definition of cardiovascular disease considered at risk and an overestimation of the role of comorbidities and advanced age. In a cohort of patients with undetermined syncope, we prospectively compared the short-term prognosis of patients at intermediate risk (i.e., with stable heart diseases or comorbidities, of any age) versus those at high risk for cardiogenic syncope and identified factors associated with serious events. Secondarily, we analyzed the current management of intermediate-risk patients. METHODS In a cohort of patients with undetermined syncope, we analyzed personal data, the presence of stable heart diseases or comorbidities, destination, length of hospitalization, incidence of serious events at 30 days, and costs. RESULTS In a 6-month period, 347 patients (185 male and 162 female, age 72.8 years) with undetermined syncope were enrolled, 250 at intermediate risk and 97 at high risk. Intermediate-risk patients were younger, with less frequent comorbidities and with a drastically lower incidence of serious events (0.8% vs. 27.8%, p < 0.001). Risk factors for cardiogenic syncope were the unique variable associated with serious events. Intermediate-risk patients were mostly admitted (62.8%) in an ordinary ward or into an emergency department observation unit; in the case of ordinary admission we observed a mean prolonged hospitalization (8.8 days), elevated costs ($270,183), and a high rate of unexplained syncope (51%). CONCLUSIONS According to the results of this study, the authors believe that intermediate-risk patients could be safely discharged, with potentially significant costs saving. In prognostic stratification, priority is to seek risk factors for cardiogenic syncope while advanced age, stable heart diseases, or comorbidities likely lead to inappropriate hospitalization.
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Affiliation(s)
| | | | - Michela Giovanelli
- Postgraduate School of Emergency Medicine; University of Parma; Parma Italy
| | - Giuseppe Lippi
- Laboratory of Clinical Chemistry and Haematology; Academic Hospital of Parma; Parma Italy
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Nicks BA, Hiestand BC. Syncope Risk Stratification in the Emergency Department: Another Step Forward. Acad Emerg Med 2016; 23:949-51. [PMID: 27327772 DOI: 10.1111/acem.13036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 01/02/2023]
Affiliation(s)
- Bret A. Nicks
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Brian C. Hiestand
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
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Goyal P, Maurer MS. Syncope in older adults. J Geriatr Cardiol 2016; 13:380-6. [PMID: 27594863 PMCID: PMC4984568 DOI: 10.11909/j.issn.1671-5411.2016.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 05/12/2016] [Accepted: 05/19/2016] [Indexed: 12/31/2022] Open
Affiliation(s)
- Parag Goyal
- Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
| | - Mathew S Maurer
- Clinical Cardiovascular Research Lab for the Elderly, Columbia University Medical Center, New York, NY, USA
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Kojodjojo P, Boey E, Elangovan A, Chen X, Tan Y, Singh D, Yeo WT, Lim TW, Seow SC, Sim TB. Mapping clinical journeys of Asian patients presenting to the Emergency Department with syncope: Strict adoption of international guidelines does not reduce hospitalisations. Int J Cardiol 2016; 218:212-218. [PMID: 27236117 DOI: 10.1016/j.ijcard.2016.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Limited data exists about management of syncope in Asia. The American College of Emergency Physicians (ACEP) and European Society of Cardiology (ESC) guidelines have defined the high-risk syncope patient. This study aims to determine the effectiveness of managing syncope in an Asian healthcare system and whether strict adherence of international guidelines would reduce hospitalizations. METHODS Patients attending the Emergency Department of a Singaporean tertiary hospital with syncope were identified. Clinical journeys of all patients were meticulously mapped by interrogation of a comprehensive electronic medical record system and linkages with national datasets. Primary endpoint was hospitalization. Secondary endpoints were recurrent syncope within 1year and all-cause mortality. Expected admission rates based on application of ACEP/ESC guidelines were calculated. RESULTS 638 patients (43.8±22.4years, 49.0% male) presented with syncope. 48.9% were hospitalized for 2.9±3.2days. Yields of common investigations ranged from 0 to 11.5% and no diagnosis was reached in 51.5% of patients. Diuretics use (HR 5.1, p=0.01) and prior hospitalization for syncope (HR 6.9, p<0.01) predicted recurrent syncope. Over 2.8 SD 0.3years of follow-up, 40 deaths occurred. 24 patients who died within 12months of presentation were admitted or had a firm diagnosis upon discharge. Application of guidelines did not significantly reduce hospitalisations, with limited agreement which patients warrant admission. (Actual 376, ACEP 354, ESC 391 admissions, p=NS). CONCLUSIONS Unstructured management of syncope results in nearly half of patients being admitted and substantial healthcare expenditures, yet with limited diagnostic yield. Strict adoption of ACEP or ESC guidelines does not reduce admissions.
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Affiliation(s)
- Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore.
| | - Elaine Boey
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Anita Elangovan
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Xianyi Chen
- Department of Emergency Medicine, National University Hospital, Singapore
| | - Yuquan Tan
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Devinder Singh
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Wee Tiong Yeo
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Swee Chong Seow
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Tiong Beng Sim
- Department of Emergency Medicine, National University Hospital, Singapore
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Solbiati M, Costantino G, Casazza G, Dipaola F, Galli A, Furlan R, Montano N, Sheldon R. Implantable loop recorder versus conventional diagnostic workup for unexplained recurrent syncope. Cochrane Database Syst Rev 2016; 4:CD011637. [PMID: 27092427 PMCID: PMC8782592 DOI: 10.1002/14651858.cd011637.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The most recent syncope guideline recommends that implantable loop recorders (ILRs) are implanted in the early phase of evaluation of people with recurrent syncope of uncertain origin in the absence of high-risk criteria, and in high-risk patients after a negative evaluation. Observational and case-control studies have shown that loop recorders lead to earlier diagnosis and reduce the rate of unexplained syncopes, justifying their use in clinical practice. However, only randomised clinical trials with an emphasis on a primary outcome of specific ILR-guided diagnosis and therapy, rather than simply electrocardiogram (ECG) diagnosis, might change clinical practice. OBJECTIVES To assess the incidence of mortality, quality of life, adverse events and costs of ILRs versus conventional diagnostic workup in people with unexplained syncope. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2015), MEDLINE, EMBASE, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Search Portal in April 2015. No language restriction was applied. SELECTION CRITERIA We included all randomised controlled trials of adult participants (i.e. ≥ 18 years old) with a diagnosis of unexplained syncope comparing ILR with standard diagnostic workup. DATA COLLECTION AND ANALYSIS Two independent review authors screened titles and abstracts of all potential studies we identified as a result of the literature search, extracted study characteristics and outcome data from included studies and assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We contacted authors of trials for missing data. We analysed dichotomous data (all-cause mortality and aetiologic diagnosis) as risk ratios (RR) with 95% confidence intervals (CI). We used the Chi(2) test to assess statistical heterogeneity (with P < 0.1) and the I² statistic to measure heterogeneity among the trials. We created a 'Summary of findings' table using the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes. MAIN RESULTS We included four trials involving a total of 579 participants. With the limitation that only two studies reported data on mortality and none of them had considered death as a primary endpoint, the meta-analysis showed no evidence of a difference in the risk of long-term mortality between participants who received ILR and those who were managed conventionally at follow-up (RR 0.97, 95% CI 0.41 to 2.30; participants = 255; studies = 2; very low quality evidence) with no evidence of heterogeneity. No data on short term mortality were available. Two studies reported data on adverse events after ILR implant. Due to the lack of data on adverse events in one of the studies' arms, a formal meta-analysis was not performed for this outcome.Data from two trials seemed to show no difference in quality of life, although this finding was not supported by a formal analysis due to the differences in both the scores used and the way the data were reported. Data from two studies seemed to show a trend towards a reduction in syncope relapses after diagnosis in participants implanted with ILR. Cost analyses from two studies showed higher overall mean costs in the ILR group, if the costs incurred by the ILR implant were counted. The mean cost per diagnosis and the mean cost per arrhythmic diagnosis were lower for participants randomised to ILR implant.Participants who underwent ILR implantation experienced higher rates of diagnosis (RR (in favour of ILR) 0.61, 95% CI 0.54 to 0.68; participants = 579; studies = 4; moderate quality evidence), as compared to participants in the standard assessment group, with no evidence of heterogeneity. AUTHORS' CONCLUSIONS Our systematic review shows that there is no evidence that an ILR-based diagnostic strategy reduces long-term mortality as compared to a standard diagnostic assessment (very low quality evidence). No data were available for short-term all-cause mortality. Moderate quality evidence shows that an ILR-based diagnostic strategy increases the rate of aetiologic diagnosis as compared to a standard diagnostic pathway. No conclusive data were available on the other end-points analysed.Further trials evaluating the effect of ILRs in the diagnostic strategy of people with recurrent unexplained syncope are warranted. Future research should focus on the assessment of the ability of ILRs to change clinically relevant outcomes, such as quality of life, syncope relapse and costs.
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Affiliation(s)
- Monica Solbiati
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoDipartimento di Medicina Interna e Specializzazioni MedicheVia Francesco Sforza 35MilanItaly20122
- Università degli Studi di MilanoDipartimento di Scienze Cliniche e di ComunitàVia Francesco Sforza 35MilanMIItaly20122
| | - Giorgio Costantino
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoDipartimento di Medicina Interna e Specializzazioni MedicheVia Francesco Sforza 35MilanItaly20122
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
| | - Franca Dipaola
- Humanitas University ‐ Humanitas Research HospitalDepartment of Biomedical SciencesVia Manzoni 113RozzanoMilanoItaly20089
| | - Andrea Galli
- AO di VimercateEmergency Departmentvia SS Cosma e DamianoVimercateMonza e BrianzaItaly
| | - Raffaello Furlan
- Humanitas University ‐ Humanitas Research HospitalDepartment of Biomedical SciencesVia Manzoni 113RozzanoMilanoItaly20089
| | - Nicola Montano
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoDipartimento di Medicina Interna e Specializzazioni MedicheVia Francesco Sforza 35MilanItaly20122
- Università degli Studi di MilanoDipartimento di Scienze Cliniche e di ComunitàVia Francesco Sforza 35MilanMIItaly20122
| | - Robert Sheldon
- University of CalgaryDepartment of Cardiac Sciences3280 Hospital Drive NWCalgaryABCanadaT2N 4N1
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Observation Services Linked With an Urgent Care Center in the Absence of an Emergency Department: An Innovative Mechanism to Initiate Efficient Health Care Delivery in the Aftermath of a Natural Disaster. Disaster Med Public Health Prep 2016; 10:405-10. [DOI: 10.1017/dmp.2016.49] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveThe emergency department (ED) of NYU Langone Medical Center was destroyed by Hurricane Sandy, contributing to a public health disaster in New York City. We evaluated hospital-based acute care provided through the establishment of an urgent care center with an associated ED-run observation service (EDOS) that operated in the absence of an ED during this disaster.MethodsWe conducted a retrospective cohort study of all patients placed in an EDOS following a visit to an urgent care center during the 18 months of ED closure. We reviewed diagnoses, clinical protocols, selection criteria, and performance metrics.ResultsOf 55,723 urgent care center visits, 15,498 patients were hospitalized, and 3167 of all hospitalized patients (20.4%) were placed in the EDOS. A total of 2660 EDOS patients (84%) were discharged from the EDOS. The 8 most frequently utilized clinical protocols accounted for 76% of the EDOS volume.ConclusionsA diverse group of patients presenting to an urgent care center following the destruction of an ED by natural disaster can be cared for in an EDOS, regardless of association with a physical ED. An urgent care center with an associated EDOS can be implemented to provide patient care in a disaster situation. This may be useful when existing ED or hospital resources are compromised. (Disaster Med Public Health Preparedness. 2016;10:405–410)
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Wheatley M, Baugh C, Osborne A, Clark C, Shayne P, Ross M. A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency. Acad Emerg Med 2016; 23:482-92. [PMID: 26806664 DOI: 10.1111/acem.12909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/20/2015] [Accepted: 10/30/2015] [Indexed: 11/29/2022]
Abstract
The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit (OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine (EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EM's two major specialty societies: the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP). The curriculum consists of didactic, clinical, and self-directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored.
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Affiliation(s)
| | | | - Anwar Osborne
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Carol Clark
- Department of Emergency Medicine; William Beaumont Health System; Troy MI
| | - Philip Shayne
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Michael Ross
- Department of Emergency Medicine; Emory University; Atlanta GA
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Puppala VK, Akkaya M, Dickinson O, Benditt DG. Risk Stratification of Patients Presenting with Transient Loss of Consciousness. Cardiol Clin 2016; 33:387-96. [PMID: 26115825 DOI: 10.1016/j.ccl.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Important goals in the initial evaluation of patients with transient loss of consciousness include determining whether the episode was syncope and choosing the venue for subsequent care. Patients who have high short-term risk of adverse outcomes need prompt hospitalization for diagnosis and/or treatment, whereas others may be safely referred for outpatient evaluation. This article summarizes the most important available risk assessment studies and points out key differences among the existing recommendations. Current risk stratification methods cannot replace critical assessment by an experienced physician, but they do provide much needed guidance and offer direction for future risk stratification consensus development.
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Affiliation(s)
- Venkata Krishna Puppala
- St Joseph Hospital, Healtheast Care System, Department of Medicine, St Paul, MN 55101, USA; Cardiac Arrhythmia Center, University of Minnesota Medical School, MMC 508, 420 Delaware Street Southeast, Minneapolis, MN 55455, USA
| | - Mehmet Akkaya
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Oana Dickinson
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - David G Benditt
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia Center, University of Minnesota Medical Center, University of Minnesota Medical School, MMC 508, 420 Delaware Street Southeast, Minneapolis, MN 55455, USA.
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80
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Akdemir B, Krishnan B, Senturk T, Benditt DG. Syncope: Assessment of risk and an approach to evaluation in the emergency department and urgent care clinic. Indian Pacing Electrophysiol J 2016; 15:103-9. [PMID: 26937094 PMCID: PMC4750139 DOI: 10.1016/j.ipej.2015.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Syncope is among the most frequent forms of transient loss of consciousness (TLOC), and is characterized by a relatively brief and self-limited loss of consciousness that by definition is triggered by transient cerebral hypoperfusion. Most often, syncope is caused by a temporary drop of systemic arterial pressure below that required to maintain cerebral function, but brief enough not to cause permanent structural brain injury. Currently, approximately one-third of syncope/collapse patients seen in the emergency department (ED) or urgent care clinic are admitted to hospital for evaluation. The primary objective of developing syncope/TLOC risk stratification schemes is to provide guidance regarding the immediate prognostic risk of syncope patients presenting to the ED or clinic; thereafter, based on that risk assessment physicians may be better equipped to determine which patients can be safely evaluated as outpatients, and which require hospital care. In general, the need for hospitalization is determined by several key issues: i) the patient's immediate (usually considered 1 week to 1 month) mortality risk and risk for physical injury (e.g., falls risk), ii) the patient's ability to care for him/herself, and iii) whether certain treatments inherently require in-hospital initiation (e.g., pacemaker implantation). However, at present no single risk assessment protocol appears to be satisfactory for universal application, and development of a consensus recommendation is an essential next step.
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Affiliation(s)
- Baris Akdemir
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Balaji Krishnan
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Tunay Senturk
- Department of Cardiology, Uludag University School of Medicine, Turkey
| | - David G. Benditt
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, United States
- Corresponding author
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81
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Courtheix M, Jalal Z, Bordachar P, Iriart X, Pillois X, Escobedo C, Rabot C, Tribout L, Thambo JB. Syncope unit in the paediatric population: A single-centre experience. Arch Cardiovasc Dis 2016; 109:199-206. [PMID: 26782626 DOI: 10.1016/j.acvd.2015.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 11/01/2015] [Accepted: 11/05/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Syncopes are frequent in the paediatric population. Most are benign, but rare cases are caused by cardiac life-threatening diseases. Syncope units developed in the adult population have demonstrated improvement in evaluation and treatment, with a reduction in hospitalization. AIMS We report our experience of paediatric syncope management in a dedicated unit, and analyse the value of different elements in the identification of cardiac causes. METHODS This prospective study included 97 consecutive patients (mean age: 12.1±3.3 years) referred between January 2011 and June 2013 to a syncope unit with a paediatric cardiologist, a nurse, a physiotherapist and a psychologist. Patients were classified into diagnostic categories after an initial evaluation that included history, physical examination, electrocardiography, echocardiography and Holter monitoring. RESULTS The most common diagnosis was neurocardiogenic syncope (n=69, 70.4%). Fifty-two cases (81.3%) had no or less recurrence after specific management that included physiotherapy and psychological support (follow-up: 11.5±5.4 months). Psychogenic pseudosyncopes affected 20 children (20.6%). Two patients had epileptic seizures. There were five cases of cardiac syncope (5.1%): two long QT syndromes and a catecholaminergic polymorphic ventricular tachycardia received beta-blockers; two atrioventricular complete blocks required pacemakers. One case was of indeterminate cause and received an insertable loop recorder after exhaustive investigations. Exercise-induced syncopes were significantly associated with cardiac origins (P=0.003), such as electrocardiographic abnormalities (P<0.001), whereas echocardiography was not contributive. CONCLUSION Syncope units in the paediatric population may be useful in the diagnostic process, to help identify rare cardiac aetiologies, and could decrease recurrence through specific management.
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Affiliation(s)
- Mathieu Courtheix
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France.
| | - Zakaria Jalal
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Pierre Bordachar
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Xavier Iriart
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Xavier Pillois
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Cécile Escobedo
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Catherine Rabot
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Laetitia Tribout
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Jean-Benoit Thambo
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
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82
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Validation of EGSYS Score in Prediction of Cardiogenic Syncope. Emerg Med Int 2015; 2015:515370. [PMID: 26649200 PMCID: PMC4663288 DOI: 10.1155/2015/515370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/18/2015] [Accepted: 11/01/2015] [Indexed: 12/04/2022] Open
Abstract
Introduction. Evaluation of Guidelines in Syncope Study (EGSYS) is designed to differentiate between cardiac and noncardiac causes of syncope. The present study aimed to evaluate the accuracy of this predictive model. Methods. In this prospective cross-sectional study, screening performance characteristics of EGSYS-U (univariate) and EGSYS-M (multivariate) in prediction of cardiac syncope were calculated for syncope patients who were referred to the emergency department (ED). Results. 198 patients with mean age of 59.26 ± 19.5 years were evaluated (62.3% male). 115 (58.4%) patients were diagnosed with cardiac syncope. Area under the ROC curve was 0.818 (95% CI: 0.75–0.87) for EGSYS-U and 0.805 (CI 95%: 0.74–0.86) for EGSYS-M (p = 0.53). Best cut-off point for both models was ≥3. Sensitivity and specificity were 86.08% (95% CI: 78.09–91.59) and 68.29% (95% CI: 56.97–77.86) for EGSYS-U and 91.30% (95% CI: 84.20–95.52) and 57.32% (95% CI: 45.92–68.02) for EGSYS-M, respectively. Conclusion. The results of this study demonstrated the acceptable accuracy of EGSYS score in predicting cardiogenic causes of syncope at the ≥3 cut-off point. It seems that using this model in daily practice can help physicians select at risk patients and properly triage them.
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83
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Automated Computer-Assisted Diagnosis of Obstructive Coronary Artery Disease in Emergency Department Patients Undergoing 256-Slice Coronary Computed Tomography Angiography for Acute Chest Pain. Am J Cardiol 2015; 116:1017-21. [PMID: 26251004 DOI: 10.1016/j.amjcard.2015.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 11/22/2022]
Abstract
A 256-slice coronary computed tomography angiography (CCTA) is an accurate method for detection and exclusion of obstructive coronary artery disease (OBS-CAD). However, accurate image interpretation requires expertise and may not be available at all hours. The purpose of this study was to evaluate the usefulness of a fully automated computer-assisted diagnosis (COMP-DIAG) tool for exclusion of OBS-CAD in patients in the emergency department (ED) presenting with chest pain. Three hundred sixty-nine patients in ED without known coronary disease underwent 256-slice CCTA as part of the assessment of chest pain of uncertain origin. COMP-DIAG (CorAnalyzer II) automatically reported presence or exclusion of OBS-CAD (>50% stenosis, ≥1 vessel). Performance characteristics of COMP-DIAG for exclusion and detection of OBS-CAD were determined using expert reading as the reference standard. Seventeen (5%) studies were unassessable by COMP-DIAG software, and 352 patients (1,056 vessels) were therefore available for analysis. COMP-DIAG identified 33% of assessable studies as having OBS-CAD, but the prevalence of OBS-CAD on CCTA was only 18% (66 of 352 patients) by standard expert reading. However, COMP-DIAG correctly identified 61 of the 66 patients (93%) with OBS-CAD with 21 vessels (2%) with OBS-CAD misclassified as negative. In conclusion, compared to expert reading, automated computer-assisted diagnosis using the CorAnalyzer showed high sensitivity but only moderate specificity for detection of obstructive coronary disease in patients in ED who underwent 256-slice CCTA. The high negative predictive value of this computer-assisted algorithm may be useful in the ED setting.
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84
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Kanters TA, Wolff C, Boyson D, Kouakam C, Dinh T, Hakkaart L, Rutten-Van Mölken MPMH. Cost comparison of two implantable cardiac monitors in two different settings: Reveal XT in a catheterization laboratory vs. Reveal LINQ in a procedure room. Europace 2015; 18:919-24. [PMID: 26293624 DOI: 10.1093/europace/euv217] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/26/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS Implantable cardiac monitors (ICMs) are used for long-term heart rhythm monitoring, e.g. to diagnose unexplained syncope or for detection of suspected atrial and ventricular arrhythmias. The newest ICM, Reveal LINQ™ (Medtronic Inc.), is miniaturized and inserted with a specific insertion tool kit. The procedure is therefore minimally invasive and can be moved from catheterization laboratory (cath lab) to a less resource intensive setting. This study aims to assess the change in procedure costs when performed outside the cath lab. METHODS AND RESULTS A bottom-up costing methodology was used. Data were collected from interviews with physicians, cath lab managers, and financial controllers. Hospitals in the Netherlands, France, and the UK were included in this study. The cost comparison of a Reveal XT implantation in a cath lab setting vs. a Reveal LINQ insertion outside a cath lab resulted in an estimated reduction of €662 for the UK, €682 for the Netherlands, and €781 for France. These cost savings were primarily realized through fewer staff, less equipment, and overhead costs. The net effect on savings depends on the price differential between these two technologies. The patient care pathway can be improved due to the possibility to move the procedure out of the cath lab. CONCLUSION Inserting the miniaturized version of the ICM is simpler and faster, and the procedure can take place outside the cath lab in a less resource intensive environment. Hospitals save resources when the higher price of the Reveal LINQ does not outweigh these savings.
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Affiliation(s)
- Tim A Kanters
- Institute for Medical Technology Assessment, Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, Rotterdam 3000 DR, The Netherlands
| | - Claudia Wolff
- Department of Health Economics and Reimbursement, Medtronic, Route du Molliau 31, Tolochenaz 1131, Switzerland
| | - David Boyson
- Cardiac Catheter Suite, Queen Elizabeth the Queen Mother Hospital, Kent CT9 4AN, UK
| | - Claude Kouakam
- Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, 2 Avenue Oscar Lambret, Lille 59000, France
| | - Trang Dinh
- Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, Maastricht 6202 AZ, The Netherlands
| | - Leona Hakkaart
- Institute for Medical Technology Assessment, Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, Rotterdam 3000 DR, The Netherlands
| | - Maureen P M H Rutten-Van Mölken
- Institute for Medical Technology Assessment, Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, Rotterdam 3000 DR, The Netherlands
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85
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Costantino G, Sun BC, Barbic F, Bossi I, Casazza G, Dipaola F, McDermott D, Quinn J, Reed MJ, Sheldon RS, Solbiati M, Thiruganasambandamoorthy V, Beach D, Bodemer N, Brignole M, Casagranda I, Del Rosso A, Duca P, Falavigna G, Grossman SA, Ippoliti R, Krahn AD, Montano N, Morillo CA, Olshansky B, Raj SR, Ruwald MH, Sarasin FP, Shen WK, Stiell I, Ungar A, Gert van Dijk J, van Dijk N, Wieling W, Furlan R. Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department. Eur Heart J 2015; 37:1493-8. [PMID: 26242712 DOI: 10.1093/eurheartj/ehv378] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/21/2015] [Indexed: 02/01/2023] Open
Affiliation(s)
- Giorgio Costantino
- Dipartimento di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Portland, Italy
| | - Benjamin C Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Franca Barbic
- BIOMETRA Department - Humanitas Research Hospital, Università degli Studi di Milano, Rozzano, MI, Italy
| | - Ilaria Bossi
- Emergency Medicine Department, S. Anna Hospital, Como, Italy
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences 'L. Sacco', Università degli Studi di Milano, Milan, Italy
| | - Franca Dipaola
- BIOMETRA Department - Humanitas Research Hospital, Università degli Studi di Milano, Rozzano, MI, Italy
| | - Daniel McDermott
- School of Medicine, University of California- San Francisco, San Francisco, CA, USA
| | - James Quinn
- Division of Emergency Medicine, Stanford University, Stanford, CA, USA
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert S Sheldon
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada
| | - Monica Solbiati
- Dipartimento di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Portland, Italy
| | | | | | | | | | - Ivo Casagranda
- Department of Emergency Medicine, Ospedale di Alessandria, Alessandria, Italy
| | - Attilio Del Rosso
- Electrophysiology Unit, Cardiology Division, Department of Medicine, Ospedale S. Giuseppe, Empoli, Italy
| | - Piergiorgio Duca
- Department of Biomedical and Clinical Sciences 'L. Sacco', Università degli Studi di Milano, Milan, Italy
| | | | - Shamai A Grossman
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Nicola Montano
- Dipartimento di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Portland, Italy
| | - Carlos A Morillo
- McMaster University, Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Medical Center, Iowa City, IA, USA
| | - Satish R Raj
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Martin H Ruwald
- Division of Cardiology, Gentofte Hospital, Copenhagen, Denmark
| | - Francois P Sarasin
- Division of Emergency Medicine, Hopital Cantonal, University of Geneva Medical School, Geneva, Switzerland
| | | | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Andrea Ungar
- Syncope Unit, Geriatric Medicine and Cardiology, Careggi University Hospital, Firenze, Italy
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nynke van Dijk
- Department of General Practice/Family Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Raffaello Furlan
- BIOMETRA Department - Humanitas Research Hospital, Università degli Studi di Milano, Rozzano, MI, Italy
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86
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Thiruganasambandamoorthy V, Taljaard M, Stiell IG, Sivilotti MLA, Murray H, Vaidyanathan A, Rowe BH, Calder LA, Lang E, McRae A, Sheldon R, Wells GA. Emergency department management of syncope: need for standardization and improved risk stratification. Intern Emerg Med 2015; 10:619-27. [PMID: 25918108 DOI: 10.1007/s11739-015-1237-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/27/2015] [Indexed: 11/28/2022]
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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87
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88
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Patel PR, Quinn JV. Syncope: a review of emergency department management and disposition. Clin Exp Emerg Med 2015; 2:67-74. [PMID: 27752576 PMCID: PMC5052859 DOI: 10.15441/ceem.14.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 01/22/2015] [Accepted: 03/01/2015] [Indexed: 11/23/2022] Open
Abstract
Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion with spontaneous return to baseline function without intervention. It is a common chief complaint of patients presenting to the emergency department. The differential diagnosis for syncope is broad and the management varies significantly depending on the underlying etiology. In the emergency department, determining the cause of a syncopal episode can be difficult. However, a thorough history and certain physical exam findings can assist in evaluating for life-threatening diagnoses. Risk-stratifying patients into low, moderate and high-risk groups can assist in medical decision making and help determine the patient's disposition. Advancements in ambulatory monitoring have made it possible to obtain prolonged cardiac evaluations of patients in the outpatient setting. This review will focus on the diagnosis and management of the various types of syncope.
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Affiliation(s)
- Pranjal R Patel
- Division of Emergency Medicine, Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - James V Quinn
- Division of Emergency Medicine, Department of Surgery, Stanford University, Palo Alto, CA, USA
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89
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Abstract
Syncope is a common symptom, experienced by 15% of persons less than 18 years old and up to 23% of elderly nursing home residents, so it is important to consider optimizing strategies for the management of these patients. The strategy selected will inevitably differ from place to place. However, an organized structure offers more cost-effective care. This article discusses possible health care delivery models for syncope management and reviews the current status of the organization of syncope care, to show the value of a multidisciplinary approach to the organized management of patients with syncope.
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Affiliation(s)
- Rose Anne Kenny
- School of Medicine, Trinity College Dublin, Health Sciences Institute, St James's Hospital, Dublin 8, Ireland.
| | - Ciara Rice
- School of Medicine, Trinity College Dublin, Health Sciences Institute, St James's Hospital, Dublin 8, Ireland
| | - Lisa Byrne
- School of Medicine, Trinity College Dublin, Health Sciences Institute, St James's Hospital, Dublin 8, Ireland
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90
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Abstract
Patients with syncope and organic heart disease remain a small but important subset of those patients who experience transient loss of consciousness. These patients require thoughtful and complete evaluation in an attempt to better understand the mechanism of syncope and its relationship to the underlying disease, and to diagnose and treat both properly. The goal is to reduce the risk of further syncope, to improve long-term outcomes with respect to arrhythmic and total mortality, and to improve patients' quality of life.
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91
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Kenny RA, Brignole M, Dan GA, Deharo JC, van Dijk JG, Doherty C, Hamdan M, Moya A, Parry SW, Sutton R, Ungar A, Wieling W. Syncope Unit: rationale and requirement--the European Heart Rhythm Association position statement endorsed by the Heart Rhythm Society. Europace 2015; 17:1325-40. [PMID: 26108809 DOI: 10.1093/europace/euv115] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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92
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Ungar A, Tesi F, Chisciotti VM, Pepe G, Vanni S, Grifoni S, Balzi D, Rafanelli M, Marchionni N, Brignole M. Assessment of a structured management pathway for patients referred to the Emergency Department for syncope: results in a tertiary hospital. Europace 2015; 18:457-62. [DOI: 10.1093/europace/euv106] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 03/18/2015] [Indexed: 11/15/2022] Open
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93
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Solbiati M, Costantino G, Casazza G, Dipaola F, Galli A, Furlan R, Montano N, Sheldon R. Implantable loop recorder versus conventional diagnostic workup for unexplained recurrent syncope. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Christ M, Geier F, Popp S, Singler K, Smolarsky A, Bertsch T, Müller C, Greve Y. Diagnostic and prognostic value of high-sensitivity cardiac troponin T in patients with syncope. Am J Med 2015; 128:161-170.e1. [PMID: 25447619 DOI: 10.1016/j.amjmed.2014.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/07/2014] [Accepted: 09/08/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We examined the diagnostic and predictive value of high-sensitivity cardiac troponin T (cTnThs) in patients with syncope. METHODS We performed an analysis of consecutive patients with syncope presenting to the emergency department. The primary end point was the accuracy to diagnose a cardiac syncope. In addition, the study explored the prognostic relevance of cTnThs in patients with cardiac and noncardiac syncope. RESULTS A total of 360 patients were enrolled (median age, 70.5 years; male, 55.8%; 23.9% aged >80 years). Cardiac syncope was present in 22% of patients, reflex syncope was present in 40% of patients, syncope due to orthostatic hypotension was present in 20% of patients, and unexplained syncope was present in 17.5% of patients. A total of 148 patients (41%) had cTnThs levels above the 99% confidence interval (CI) (cutoff point). The diagnostic accuracy for cTnThs levels to determine the diagnosis of cardiac syncope was quantified by the area under the curve (0.77; CI, 0.72-0.83; P < .001). A comparable area under the curve (0.78; CI, 0.73-0.83; P < .001) was obtained for the predictive value of cTnThs levels within 30 days: Patients with increased cTnThs levels had a 52% likelihood for adverse events, patients with cTnThs levels below the cutoff point had a low risk (negative predictive value, 83.5%). Increased cTnThs levels indicate adverse prognosis in patients with noncardiac causes of syncope, but not in patients with cardiac syncope being a risk factor for adverse outcome by itself. CONCLUSIONS Patients with syncope presenting to the emergency department have a high proportion of life-threatening conditions. cTnThs levels show a limited diagnostic and predictive accuracy for the identification of patients with syncope at high risk.
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Affiliation(s)
- Michael Christ
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany.
| | - Felicitas Geier
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Steffen Popp
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Katrin Singler
- Institute for Biomedicine of Aging, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Alexander Smolarsky
- Center of Trauma and Orthopaedic Surgery, Helios Vogtland-Klinikum Plauen, Plauen, Germany
| | - Thomas Bertsch
- Department of Clinical Chemistry and Laboratory Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Christian Müller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Yvonne Greve
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
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95
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Peacock F, Beckley P, Clark C, Disch M, Hewins K, Hunn D, Kontos MC, Levy P, Mace S, Melching KS, Ordonez E, Osborne A, Suri P, Sun B, Wheatley M. Recommendations for the evaluation and management of observation services: a consensus white paper: the Society of Cardiovascular Patient Care. Crit Pathw Cardiol 2014; 13:163-198. [PMID: 25396295 DOI: 10.1097/hpc.0000000000000033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. A well-structured observation program will help hospitals reduce the number of inappropriate, costly inpatient admissions while avoiding the potential of inappropriate discharges. Observation medicine is a complicated multidimensional issue that has generated much confusion. This service is designed to provide the best possible patient care in a value-based purchasing environment where quality, cost, and patient satisfaction must continually be addressed. Observation medicine is a service not a status. Therefore, patients are admitted to the service as outpatients no matter whether they are placed in a virtual or dedicated observation unit. The key to a successful observation program is to determine how to maximize efficiencies. This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.
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Affiliation(s)
- Frank Peacock
- From the *Baylor College of Medicine, Ben Taub Hospital, Houston, TX; †Society of Cardiovascular Patient Care, Dublin, OH; ‡Beaumont Health System, Royal Oaks, MI; §Virginia Commonwealth University Medical Center, Richmond, VA; ¶Wayne State University School of Medicine, Detroit, MI; ‖Cleveland Clinic, Cleveland, OH; **Emory University School of Medicine, Atlanta, GA; and ††Oregon Health & Science University, Portland, OR
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96
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Abstract
Syncope is defined as transient loss of consciousness due to global cerebral hypoperfusion. It is characterized by having a relatively rapid onset, brief duration with spontaneous and full recovery. The major challenge in the evaluation of patients with syncope is that most patients are asymptomatic at the time of their presentation. A thorough history and physical examination including orthostatic assessment are crucial for making the diagnosis. After initial evaluation, short-term risk assessment should be performed to determine the need for admission. If the short-term risk is high, inpatient evaluation is needed. If the short-term risk is low, outpatient evaluation is recommended. In patients with suspected cardiac syncope, monitoring is indicated until a diagnosis is made. In patients with suspected reflex syncope or orthostatic hypotension, outpatient evaluation with tilt-table testing is appropriate. Syncope units have been shown to improve the rate of diagnosis while reducing cost and thus are highly recommended.
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97
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Probst MA, Sun BC. How can we improve management of syncope in the Emergency Department? Cardiol J 2014; 21:643-50. [PMID: 25299508 PMCID: PMC5110209 DOI: 10.5603/cj.a2014.0074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 09/18/2014] [Indexed: 11/25/2022] Open
Abstract
Syncope is a common and challenging presenting complaint to the Emergency Department (ED). Despite substantial research efforts, there is still considerable uncertainty about the optimal ED management of syncope. There is continued interest among clinicians and researchers in improving diagnostic algorithms and optimizing resource utilization. In this paper, we discuss 4 strategies to improve the emergency care of syncope patients: (1) Development of accurate and consistent risk-stratification, (2) Increased use of syncope observation protocols, (3) Evaluation of a discharge with ambulatory monitoring pathway, (4) Use of shared decision-making for disposition decisions. Since current risk-stratification tools have fallen short with regard to subsequent validation and implementation into clinical practice, we outline key factors for future risk-stratification research. We propose that observation units have the potential to safely decrease length-of-stay and hospital costs for hemodynamically stable, intermediate risk patients without adversely affecting clinical outcomes. For appropriate patients with a negative ED evaluation, we recommend consideration of direct discharge, with ambulatory monitoring and expedited follow-up, as a means of decreasing costs and reducing iatrogenic harms. Finally, we advocate for the use of shared decision-making regarding the ultimate disposition of select, intermediate risk patients who have not had a serious condition revealed in the ED. If properly implemented, these four strategies could significantly improve the care of ED syncope patients by helping clinicians identify truly high-risk patients, decreasing unnecessary hospitalizations, and increasing patient satisfaction.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, United States.
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98
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Ray JC, Kusumoto F, Goldschlager N. Syncope. J Intensive Care Med 2014; 31:79-93. [PMID: 25286917 DOI: 10.1177/0885066614552988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/26/2014] [Indexed: 11/17/2022]
Abstract
Syncope is common representing approximately 3% of ED visits and up to 6% of hospital admissions, with a cost close to 2 billion dollars per year. Diagnostic testing is often poorly sensitive and evaluations commonly lack a standardized approach. A mindful and systematic approach can increase sensitivity and improve diagnostic accuracy. A thorough history and physical exam is paramount, as conclusions drawn from the history and exam will guide further assessment. Developing a strategy for the first and, if necessary, subsequent tests will improve the accuracy of identifying the etiology of syncope and reduce cost. Although syncope has a favorable prognosis, identification of patients with structural heart disease is critical, as these patients are at greatest risk for mortality. Several risk scoring systems have been developed to help separate high risk from low risk patients.
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Affiliation(s)
- Jordan C Ray
- Division of Cardiovascular disease, Department of Medicine, Electrophysiology and Pacing Service, Mayo Clinic, Jacksonville, FL, USA
| | - Fred Kusumoto
- Division of Cardiovascular disease, Department of Medicine, Electrophysiology and Pacing Service, Mayo Clinic, Jacksonville, FL, USA
| | - Nora Goldschlager
- Cardiology Division, Department of Medicine, San Francisco General Hospital, San Francisco, CA, USA Department of Medicine, University of California, San Francisco, CA, USA
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99
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Martens L, Goode G, Wold JFH, Beck L, Martin G, Perings C, Stolt P, Baggerman L. Structured syncope care pathways based on lean six sigma methodology optimises resource use with shorter time to diagnosis and increased diagnostic yield. PLoS One 2014; 9:e100208. [PMID: 24927475 PMCID: PMC4057404 DOI: 10.1371/journal.pone.0100208] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 05/23/2014] [Indexed: 11/18/2022] Open
Abstract
Aims To conduct a pilot study on the potential to optimise care pathways in syncope/Transient Loss of Consciousness management by using Lean Six Sigma methodology while maintaining compliance with ESC and/or NICE guidelines. Methods Five hospitals in four European countries took part. The Lean Six Sigma methodology consisted of 3 phases: 1) Assessment phase, in which baseline performance was mapped in each centre, processes were evaluated and a new operational model was developed with an improvement plan that included best practices and change management; 2) Improvement phase, in which optimisation pathways and standardised best practice tools and forms were developed and implemented. Staff were trained on new processes and change-management support provided; 3) Sustaining phase, which included support, refinement of tools and metrics. The impact of the implementation of new pathways was evaluated on number of tests performed, diagnostic yield, time to diagnosis and compliance with guidelines. One hospital with focus on geriatric populations was analysed separately from the other four. Results With the new pathways, there was a 59% reduction in the average time to diagnosis (p = 0.048) and a 75% increase in diagnostic yield (p = 0.007). There was a marked reduction in repetitions of diagnostic tests and improved prioritisation of indicated tests. Conclusions Applying a structured Lean Six Sigma based methodology to pathways for syncope management has the potential to improve time to diagnosis and diagnostic yield.
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Affiliation(s)
- Leon Martens
- Medtronic Hospital Solutions, Heerlen, The Netherlands
| | - Grahame Goode
- Blackpool Victoria Hospital, Blackpool, United Kingdom
| | | | - Lionel Beck
- Centre Hospitalier Universitaire Carémeau, Nîmes, France
| | - Georgina Martin
- Northern General/Royal Hallamshire Hospital, Sheffield, United Kingdom
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100
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Sun BC, Costantino G, Barbic F, Bossi I, Casazza G, Dipaola F, McDermott D, Quinn J, Reed M, Sheldon RS, Solbiati M, Thiruganasambandamoorthy V, Krahn AD, Beach D, Bodemer N, Brignole M, Casagranda I, Duca P, Falavigna G, Ippoliti R, Montano N, Olshansky B, Raj SR, Ruwald MH, Shen WK, Stiell I, Ungar A, van Dijk JG, van Dijk N, Wieling W, Furlan R. Priorities for emergency department syncope research. Ann Emerg Med 2014; 64:649-55.e2. [PMID: 24882667 DOI: 10.1016/j.annemergmed.2014.04.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/01/2014] [Accepted: 04/07/2014] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVES There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research. METHODS We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process. RESULTS There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management. CONCLUSION We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED.
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Affiliation(s)
- Benjamin C Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR.
| | - Giorgio Costantino
- Division of Medicine and Pathophysiology, Università degli Studi di Milano, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Franca Barbic
- BIOMETRA Department-Humanitas Clinical and Research Center, Rozzano (MI), Università degli Studi di Milano, Milan, Italy
| | - Ilaria Bossi
- Emergency Medicine Department, S. Anna Hospital, Como, Italy
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Franca Dipaola
- BIOMETRA Department-Humanitas Clinical and Research Center, Rozzano (MI), Università degli Studi di Milano, Milan, Italy
| | - Daniel McDermott
- School of Medicine, University of California-San Francisco, San Francisco, CA
| | - James Quinn
- Division of Emergency Medicine, Stanford University, Stanford, CA
| | - Matthew Reed
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, United Kingdom
| | - Robert S Sheldon
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada
| | - Monica Solbiati
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | | | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | | | | | | | | | - Piergiorgio Duca
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | | | | | - Nicola Montano
- Division of Medicine and Pathophysiology, Università degli Studi di Milano, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Medical Center, Iowa City, IA
| | - Satish R Raj
- Departments of Medicine and Pharmacology, Vanderbilt University, Nashville, TN
| | - Martin H Ruwald
- Division of Cardiology, Gentofte Hospital, Copenhagen, Denmark
| | | | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Andrea Ungar
- Division of Geriatrics, Ospedale Careggi, Firenze, Italy
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Nynke van Dijk
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Raffaello Furlan
- BIOMETRA Department-Humanitas Clinical and Research Center, Rozzano (MI), Università degli Studi di Milano, Milan, Italy
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