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du Fay de Lavallaz J, Zimmermann T, Badertscher P, Lopez-Ayala P, Nestelberger T, Miró Ò, Salgado E, Zaytseva X, Gafner MS, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Costabel JP, Sigal A, Puelacher C, Wussler D, Koechlin L, Strebel I, Schuler S, Manka R, Bilici M, Lohrmann J, Kühne M, Breidthardt T, Clark CL, Probst M, Gibson TA, Weiss RE, Sun BC, Mueller C. Performance of the American Heart Association/American College of Cardiology/Heart Rhythm Society versus European Society of Cardiology guideline criteria for hospital admission of patients with syncope. Heart Rhythm 2022; 19:1712-1722. [PMID: 35644354 DOI: 10.1016/j.hrthm.2022.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/28/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope. OBJECTIVE The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies. METHODS The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE). RESULTS Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P <.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P <.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines. CONCLUSION ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements.
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Affiliation(s)
- Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network.
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Òscar Miró
- GREAT Network; Hospital Clinic, Barcelona, Catalonia, Spain
| | - Emilio Salgado
- GREAT Network; Hospital Clinic, Barcelona, Catalonia, Spain
| | - Xenia Zaytseva
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; University Hospital Zürich, Zürich, Switzerland
| | - Michele Sara Gafner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Michael Christ
- Department of Emergency Medicine, Kantonsspital Luzern, Lucerne, Switzerland
| | - Louise Cullen
- GREAT Network; Royal Brisbane & Women's Hospital, Herston, Australia
| | - Martin Than
- GREAT Network; Christchurch Hospital, Christchurch, New Zealand
| | | | - Salvatore Di Somma
- GREAT Network; Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Rome, Italy
| | - W Frank Peacock
- GREAT Network; Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | | | - Alan Sigal
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Sereina Schuler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; University Hospital Zürich, Zürich, Switzerland
| | | | - Murat Bilici
- Department of Orthopedics and Traumatology, Basel University Hospital, Basel, Switzerland
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Carol L Clark
- Beaumont Health System-Royal Oak, Royal Oak, Michigan
| | - Marc Probst
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York
| | - Thomas A Gibson
- Department of Biostatistics, University of California Fielding School of Public Health, Los Angeles, California
| | - Robert E Weiss
- Department of Biostatistics, University of California Fielding School of Public Health, Los Angeles, California
| | - Benjamin C Sun
- Department of Emergency Medicine, Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
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Zimmermann T, du Fay de Lavallaz J, Walter JE, Strebel I, Nestelberger T, Joray L, Badertscher P, Flores D, Widmer V, Geigy N, Miro O, Salgado E, Christ M, Cullen L, Than M, Martín-Sánchez FJ, Di Somma S, Peacock WF, Keller D, Costabel JP, Wussler DN, Kawecki D, Lohrmann J, Gualandro DM, Kuehne M, Reichlin T, Sun B, Mueller C. Development of an electrocardiogram-based risk calculator for a cardiac cause of syncope. Heart 2021; 107:1796-1804. [PMID: 33504514 DOI: 10.1136/heartjnl-2020-318430] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/31/2020] [Accepted: 01/03/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To develop an ECG-based tool for rapid risk assessment of a cardiac cause of syncope in patients ≥40 years. METHODS In a prospective international multicentre study, 2007 patients ≥40 years presenting with syncope were recruited in the emergency department (ED) of participating centres ranging from large university hospitals to smaller rural hospitals in eight countries from May 2010 to July 2017. 12-Lead ECG recordings were obtained at ED presentation following the syncopal event. The primary diagnostic outcome, a cardiac cause of syncope, was centrally adjudicated by two independent cardiologists using all available clinical information including 12-month follow-up. ECG predictors for a cardiac cause of syncope were identified using penalised backward selection and a continuous-scale likelihood was calculated based on regression analysis coefficients. Findings were validated in an independent US multicentre cohort including 2269 patients. RESULTS In the derivation cohort, a cardiac cause of syncope was adjudicated in 267 patients (16%). Seven ECG criteria were identified as predictors for this outcome: heart rate and QTc-interval (continuous predictors), rhythm, atrioventricular block, ST-segment depression, bundle branch block and ventricular extrasystole/non-sustained ventricular tachycardia (categorical predictors). Diagnostic accuracy of these combined predictors for a cardiac cause of syncope was high (area under the curve 0.80, 95% CI 0.77 to 0.83). Overall, 138 patients (8%) were rapidly triaged towards rule-out and 181 patients (11%) towards rule-in of a cardiac cause of syncope. External validation showed similar performance. CONCLUSION In patients ≥40 years with a syncopal event, a combination of seven ECG criteria enabled rapid assessment of the likelihood that syncope was due to a cardiac cause. TRIAL REGISTRATION NUMBER NCT01548352 (BASEL IX), NCT01802398 (SRS study).
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Affiliation(s)
- Tobias Zimmermann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Joan Elias Walter
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Lydia Joray
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Patrick Badertscher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Dayana Flores
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Velina Widmer
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Baselland, Liestal, Switzerland
| | - Oscar Miro
- GREAT network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Switzerland
| | - Louise Cullen
- GREAT network, Rome, Italy.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Martin Than
- GREAT network, Rome, Italy.,Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - Salvatore Di Somma
- GREAT network, Rome, Italy.,Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Rome, Italy
| | - W Frank Peacock
- GREAT network, Rome, Italy.,Emergency Department, Baylor College of Medicine, Houston, Texas, USA
| | - Dagmar Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | | | - Desiree Nadine Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Damian Kawecki
- Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Jens Lohrmann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Michael Kuehne
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Tobias Reichlin
- GREAT network, Rome, Italy.,Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Benjamin Sun
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland .,GREAT network, Rome, Italy
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