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Ghariq M, van den Hout WB, Dekkers OM, Bootsma M, de Groot B, Groothuis JGJ, Harms MPM, Hemels MEW, Kaal ECA, Koomen EM, de Lange FJ, Peeters SYG, van Rossum IA, Rutten JHW, van Zwet EW, van Dijk JG, Thijs RD. Diagnostic and societal impact of implementing the syncope guidelines of the European Society of Cardiology (SYNERGY study). BMC Med 2023; 21:365. [PMID: 37743496 PMCID: PMC10518933 DOI: 10.1186/s12916-023-03056-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Syncope management is fraught with unnecessary tests and frequent failure to establish a diagnosis. We evaluated the potential of implementing the 2018 European Society of Cardiology (ESC) Syncope Guidelines regarding diagnostic yield, accuracy and costs. METHODS A multicentre pre-post study in five Dutch hospitals comparing two groups of syncope patients visiting the emergency department: one before intervention (usual care; from March 2017 to February 2019) and one afterwards (from October 2017 to September 2019). The intervention consisted of the simultaneous implementation of the ESC Syncope Guidelines with quick referral routes to a syncope unit when indicated. The primary objective was to compare diagnostic accuracy using logistic regression analysis accounting for the study site. Secondary outcome measures included diagnostic yield, syncope-related healthcare and societal costs. One-year follow-up data were used to define a gold standard reference diagnosis by applying ESC criteria or, if not possible, evaluation by an expert committee. We determined the accuracy by comparing the treating physician's diagnosis with the reference diagnosis. RESULTS We included 521 patients (usual care, n = 275; syncope guidelines intervention, n = 246). The syncope guidelines intervention resulted in a higher diagnostic accuracy in the syncope guidelines group than in the usual care group (86% vs.69%; risk ratio 1.15; 95% CI 1.07 to 1.23) and a higher diagnostic yield (89% vs. 76%, 95% CI of the difference 6 to 19%). Syncope-related healthcare costs did not differ between the groups, yet the syncope guideline implementation resulted in lower total syncope-related societal costs compared to usual care (saving €908 per patient; 95% CI €34 to €1782). CONCLUSIONS ESC Syncope Guidelines implementation in the emergency department with quick referral routes to a syncope unit improved diagnostic yield and accuracy and lowered societal costs. TRIAL REGISTRATION Netherlands Trial Register, NTR6268.
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Affiliation(s)
- M Ghariq
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - B de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G J Groothuis
- Department of Cardiology, Diakonessenhuis, Utrecht, The Netherlands
| | - M P M Harms
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E C A Kaal
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E M Koomen
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - F J de Lange
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - S Y G Peeters
- Department of Emergency Medicine, Flevo Hospital, Almere, The Netherlands
| | - I A van Rossum
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - J H W Rutten
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - R D Thijs
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
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Sutton R, Ricci F, Fedorowski A. Risk stratification of syncope: Current syncope guidelines and beyond. Auton Neurosci 2022; 238:102929. [PMID: 34968831 DOI: 10.1016/j.autneu.2021.102929] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/27/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
Syncope is an alarming event carrying the possibility of serious outcomes, including sudden cardiac death (SCD). Therefore, immediate risk stratification should be applied whenever syncope occurs, especially in the Emergency Department, where most dramatic presentations occur. It has long been known that short- and long-term syncope prognosis is affected not only by its mechanism but also by presence of concomitant conditions, especially cardiovascular disease. Over the last two decades, several syncope prediction tools have been developed to refine patient stratification and triage patients who need expert in-hospital care from those who may receive nonurgent expert care in the community. However, despite promising results, prognostic tools for syncope remain challenging and often poorly effective. Current European Society of Cardiology syncope guidelines recommend an initial syncope workup based on detailed patient's history, physical examination supine and standing blood pressure, resting ECG, and laboratory tests, including cardiac biomarkers, where appropriate. Subsequent risk stratification based on screening of features aims to identify three groups: high-, intermediate- and low-risk. The first should immediately be hospitalized and appropriately investigated; intermediate group, with recurrent or medium-risk events, requires systematic evaluation by syncope experts; low-risk group, sporadic reflex syncope, merits education about its benign nature, and discharge. Thus, initial syncope risk stratification is crucial as it determines how and by whom syncope patients are managed. This review summarizes the crucial elements of syncope risk stratification, pros and cons of proposed risk evaluation scores, major challenges in initial syncope management, and how risk stratification impacts management of high-risk/recurrent syncope.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, Dept. of Cardiology, Hammersmith Hospital, Du Cane Road, London W12 0HS, United Kingdom
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, Via Luigi Polacchi, 11, 66100 Chieti, Italy; Casa di Cura Villa Serena, Città Sant'Angelo, Italy
| | - Artur Fedorowski
- Dept. of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Stockholm, Sweden.
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Firouzbakht T, Shen ML, Groppelli A, Brignole M, Shen WK. Step-by-step guide to creating the best syncope units: From combined United States and European experiences. Auton Neurosci 2022; 239:102950. [DOI: 10.1016/j.autneu.2022.102950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
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Jusmanova K, Rice C, Bourke R, Lavan A, McMahon CG, Cunningham C, Kenny RA, Briggs R. Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness. QJM 2021; 114:32-38. [PMID: 32866245 DOI: 10.1093/qjmed/hcaa261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/22/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission. AIM To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness. DESIGN Pre- and post-cohort study. METHODS Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS). RESULTS There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4-24.0] days compared to 18.2 (95% CI 14.6-21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030). CONCLUSION This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.
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Affiliation(s)
- K Jusmanova
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| | - C Rice
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - R Bourke
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| | - A Lavan
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| | - C G McMahon
- Department of Emergency Medicine, St James's Hospital, Dublin 8, Ireland
| | - C Cunningham
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - R A Kenny
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - R Briggs
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
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Qian XL, Pan YS, Chen JJ, Jiang QQ, Huang D, Li JB. The value of multidisciplinary team in syncope clinic for the effective diagnosis of complex syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:821-827. [PMID: 31004502 DOI: 10.1111/pace.13703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/13/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Syncope is a perplexing challenge that often receives thorough evaluation, yet the diagnosis remains unclear. Usually, the emergency department is the first point at which patients present with syncope. However, diverse medical factors, including low diagnostic rates and inconsistent management by doctors, add to healthcare costs and delay diagnosis for syncope patients. METHODS Patients who had been to the emergency department at least once but were not given a clear diagnosis of syncope were recruited into our study at the time they visited syncope clinic staffed by a multidisciplinary team. Complete medical histories and clinical examinations were conducted by both experienced cardiologists and neurologists. If patients were not given a conclusive diagnosis at the syncope clinic on the basis of outpatient examinations, they were admitted for further evaluation. RESULTS A total of 209 consecutive patients claiming "syncope" visited the syncope clinic, yet only 167 patients were formally diagnosed with syncope. For these 167 patients, the mean age was 55.93 ± 17.40 years old, and 41.3% were male. The proportions of cardiac syncope, reflex syncope, orthostatic hypotension (OH), and syncope of uncertain etiology were 19.8%, 64.1%, 7.8%, and 8.4%, respectively. The diagnostic rate was 91.6%, and the hospitalization rate was 23.4%. Patients with reflex syncope and OH were younger than patients with cardiac syncope. Cardiac syncope tends to occur more frequently in males, while reflex syncope is more likely in females. CONCLUSIONS The cooperation of professional cardiologists and neurologists will play an important role in improving diagnostic rates, lowering admission rates, and reducing medical costs.
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Affiliation(s)
- Xiao-Lin Qian
- Heart Center, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
| | - Ye-Sheng Pan
- Heart Center, Tongji University Affiliated Oriental Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Jing-Jiong Chen
- Neurology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
| | - Qing-Qing Jiang
- Neurology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
| | - Dong Huang
- Heart Center, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
| | - Jing-Bo Li
- Heart Center, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
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Use of a Pediatric Syncope Unit Improves Diagnosis and Lowers Costs: A Hospital-Based Experience. J Pediatr 2018; 201:184-189.e2. [PMID: 29961647 DOI: 10.1016/j.jpeds.2018.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/26/2018] [Accepted: 05/17/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To assess the effect of a dedicated pediatric syncope unit on the diagnostic and therapeutic management of children with suspected syncope. We also evaluated the effectiveness of the pediatric syncope unit model in decreasing unnecessary tests and hospitalizations, minimizing social costs, and improving diagnostic yield. STUDY DESIGN This single-center cohort observational, prospective study enrolled 2278 consecutive children referred to Bambino Gesù Children's Hospital from 2012 to 2017. Characteristics of the study population, number and type of admission examinations, and diagnostic findings before the pediatric syncope unit was implemented (2012-2013) and after the pediatric syncope unit was implemented (2014-2015 and 2016-2017) were compared. RESULTS The proportion of undefined syncope, number of unnecessary diagnostic tests performed, and number of hospital stay days decreased significantly (P < .0001), with an overall decrease in costs. A multivariable logistic regression analysis, adjusted for confounding variables (age, sex, number of diagnostic tests), the period after pediatric syncope unit (2016-2017) resulted as the best independent predictor of effectiveness for a defined diagnosis of syncope (P < .0001). CONCLUSIONS Pediatric syncope unit organization with fast-tracking access more appropriate diagnostic tests is effective in terms of accuracy of diagnostic yield and reduction of costs.
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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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Tilt testing and what you should know about it - Experience with 835 consecutive patients with syncope of unknown origin. Int J Cardiol 2018; 258:90-96. [DOI: 10.1016/j.ijcard.2018.01.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 01/22/2018] [Indexed: 11/22/2022]
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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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Guneysu F, Saritas A, Gunes H, Turan Sonmez F, Guneysu S. Assessment of Electrocardiographic and Echocardiographic Features in Patients Admitting with Syncope. KONURALP TIP DERGISI 2017. [DOI: 10.18521/ktd.342578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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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: 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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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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Gomes DG, Kus T, Sant'anna RT, de Lima GG, Essebag V, Leiria TLL. Simple risk stratification score for prognosis of syncope. J Interv Card Electrophysiol 2016; 47:153-161. [PMID: 27394159 DOI: 10.1007/s10840-016-0165-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/29/2016] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of this study is to describe a new simple score to predict the occurrence of severe adverse events in patients admitted for syncope to a tertiary cardiology referral center. METHODS Three hundred ninety-three subjects with emergency department visits for syncope were identified and followed prospectively. The primary endpoint was death or unplanned hospital admission after the syncopal episode. The score consisted of sum of the following: previous syncope (2 points), an abnormal electrocardiogram (3 points), and history of heart disease (4 points). The accuracy of our score was compared to other scores available in the literature. RESULTS Of the 393 subjects, 87 were diagnosed with syncope secondary to structural or electrical heart disease and 306 with noncardiac syncope. The primary endpoint occurred in 202 cases, including death occurring in 25 patients during the 12-month follow-up. The 30-day event rate for the primary endpoint was 26.5 %. The c-statistic for the new score was 0.76 (95 % CI 0.71-0.80) similar to other scores when applied to our sample. Patients with a score of 3 out of 9 had a hazard ratio of 3.46 (95 % CI 1.22-6.11) for death during the follow-up. CONCLUSIONS In the study population, the new syncope score detected patients with an increased risk of death after discharge from a syncopal event. Our score predicted adverse events comparably to other scores reported in the literature. It has the advantage of being simple and easily obtained from the history and an inexpensive noninvasive test-the ECG.
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Affiliation(s)
- Daniel Garcia Gomes
- Post-Graduate Program in Health Sciences, Cardiology Institute of Rio Grande do Sul/Cardiology University Foundation, Porto Alegre, Brazil
| | - Teresa Kus
- Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Québec, Canada
| | - Roberto Tofani Sant'anna
- Post-Graduate Program in Health Sciences, Cardiology Institute of Rio Grande do Sul/Cardiology University Foundation, Porto Alegre, Brazil
| | - Gustavo Glotz de Lima
- Post-Graduate Program in Health Sciences, Cardiology Institute of Rio Grande do Sul/Cardiology University Foundation, Porto Alegre, Brazil
| | - Vidal Essebag
- Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Québec, Canada
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Tiago L Luz Leiria
- Post-Graduate Program in Health Sciences, Cardiology Institute of Rio Grande do Sul/Cardiology University Foundation, Porto Alegre, Brazil.
- Unidade de Pesquisa, Av. Princesa Isabel, 370, Santana Porto Alegre, RS, 90620-001, Brazil.
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15
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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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16
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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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18
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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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19
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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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20
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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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21
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Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, Raj SR, Krahn AD, Morillo CA, Stewart JM, Sutton R, Sandroni P, Friday KJ, Hachul DT, Cohen MI, Lau DH, Mayuga KA, Moak JP, Sandhu RK, Kanjwal K. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm 2015; 12:e41-63. [PMID: 25980576 DOI: 10.1016/j.hrthm.2015.03.029] [Citation(s) in RCA: 582] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Indexed: 01/14/2023]
Affiliation(s)
| | | | | | | | | | | | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Alberta, Canada; Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Carlos A Morillo
- Department of Medicine, Cardiology Division, McMaster University Population Health Research Institute, Hamilton, Canada
| | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Karen J Friday
- (13)Stanford University School of Medicine, Stanford, California
| | | | - Mitchell I Cohen
- Phoenix Children's Hospital, University of Arizona School of Medicine-Phoenix, Arizona Pediatric Cardiology/Mednax, Phoenix, Arizona
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide; Department of Cardiology, Royal Adelaide Hospital; and South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Jeffrey P Moak
- Children's National Medical Center, Washington, District of Columbia
| | - Roopinder K Sandhu
- University of Alberta, Department of Medicine, Division of Cardiology, Alberta, Canada
| | - Khalil Kanjwal
- Michigan Cardiovascular Institute, Central Michigan University, Saginaw, Michigan
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22
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Greve Y, Geier F, Popp S, Bertsch T, Singler K, Meier F, Smolarsky A, Mang H, Müller C, Christ M. The prevalence and prognostic significance of near syncope and syncope: a prospective study of 395 cases in an emergency department (the SPEED study). DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:197-204. [PMID: 24717304 DOI: 10.3238/arztebl.2014.0197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The prognostic significance of near-syncope has not yet been adequately characterized. METHOD We collected prospective data on a consecutive series of patients seen in an emergency department with syncope (brief loss of consciousness, usually with loss of muscle tone) or near-syncope (a feeling that syncope is about to occur, but without actual loss of consciousness or muscle tone). We report on the prevalence, etiology, and prognosis of such events (the SPEED study). Patients were followed up at 30 days and at 6 months after the event. RESULTS From 17 July to 31 October 2011, 395 patients were seen in the emergency department for a chief complaint of syncope or near-syncope (3% of all emergency patients). Their median age was 70 years, and 55% were men. 62% had experienced syncope, and 38% near-syncope. The patients with near-syncope were younger than those with syncope ( 63 vs. 72 years, p < 0.014) and were also more commonly male (63% vs. 49%, p = 0.006). The two patient groups did not differ significantly with respect to their measured laboratory values and vital parameters or their accompanying medical conditions. Hospitalizations were more common for syncope than for near-syncope (86% vs. 70%, p < 0.001). Etiologies were similarly distributed in the two patient groups, with the main ones being reflex syncope, orthostatic syncope, cardiac syncope, and syncope of uncertain origin. In all, 123 of 379 patients (32%) had further undesired events within 30 days of the event. Multivariable logistic regression revealed that age, heart rate, and renal dysfunction were independent predictors of undesired events, while the type of syncope was not. CONCLUSION Patients with near-syncope do not differ to any large extent from patients with syncope with respect to the features studied. The diagnostic evaluation should be similar for patients in the two groups.
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Affiliation(s)
- Yvonne Greve
- Department of Emergency and Critical Care Medicine, Nuremberg Hospital, Institute for Clinical Chemistry, Laboratory Medicine, and Transfusion Medicine, Nuremberg Hospital, Master Program M. Sc. Medical Process Management, Friedrich-Alexander-University Erlangen-Nürnberg, Department of Geriatrics, Nuremberg Hospital, Chairholder at the Department of Health Economics, Friedrich-Alexander-University Erlangen-Nürnberg, Departement of Internal Medicine, Universitätsspital Basel, Switzerland
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23
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Gilchrist PT, McGovern GE, Bekkouche N, Bacon SL, Ditto B. The vasovagal response during confrontation with blood-injury-injection stimuli: the role of perceived control. J Anxiety Disord 2015; 31:43-8. [PMID: 25728015 DOI: 10.1016/j.janxdis.2015.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 01/14/2015] [Accepted: 01/29/2015] [Indexed: 11/30/2022]
Abstract
The vasovagal response (VVR) is a common medical problem, complicating and deterring people from various procedures. It is an unusual stress response given the widespread decreases in physiological activity. Nevertheless, VVR involves processes similar to those observed during episodes of strong emotions and pain. We hypothesized that heightened perceived control would reduce symptoms of VVR. Eighty-two young adults were randomly assigned to perceived control or no perceived control conditions during exposure to a stimulus video of a mitral valve surgery, known to trigger VVR in non-medical personnel. Perceived control was manipulated by allowing some participants to specify a break time, though all received equivalent breaks. Outcomes included subjective symptoms of VVR, anxiety, blood pressure, heart rate, and other measures derived from impedance cardiography. Compared to participants with perceived control, participants with no perceived control reported significantly more vasovagal symptoms and anxiety, and experienced lower stroke volume, cardiac output, and diastolic blood pressure. Participants who were more fearful of blood were more likely to benefit from perceived control in several measures. Perceived control appears to reduce vasovagal symptoms. Results are discussed in terms of cognition and emotion in VVR.
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Affiliation(s)
- Philippe T Gilchrist
- Laboratory for Cardiovascular Psychophysiology, Department of Psychology, McGill University, 1205 Dr Penfield Avenue, Montreal, Quebec H3A 1B1, Canada.
| | - Gillian E McGovern
- Laboratory for Cardiovascular Psychophysiology, Department of Psychology, McGill University, 1205 Dr Penfield Avenue, Montreal, Quebec H3A 1B1, Canada
| | - Nadine Bekkouche
- Laboratory for Cardiovascular Psychophysiology, Department of Psychology, McGill University, 1205 Dr Penfield Avenue, Montreal, Quebec H3A 1B1, Canada
| | - Simon L Bacon
- Montreal Behavioural Medicine Centre and Research Centre, Hôpital du Sacré-Coeur de Montréal - A University of Montreal Affiliated Hospital, Montreal H4J 1C5, Canada; Department of Exercise Science, Concordia University, 7141 Sherbrooke Street West, Montreal, Quebec H4B 1R6, Canada
| | - Blaine Ditto
- Laboratory for Cardiovascular Psychophysiology, Department of Psychology, McGill University, 1205 Dr Penfield Avenue, Montreal, Quebec H3A 1B1, Canada
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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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25
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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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Finucane C, O’Connell MD, Fan CW, Savva GM, Soraghan CJ, Nolan H, Cronin H, Kenny RA. Age-Related Normative Changes in Phasic Orthostatic Blood Pressure in a Large Population Study. Circulation 2014; 130:1780-9. [DOI: 10.1161/circulationaha.114.009831] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In this report, we provide the first normative reference data and prevalence estimates of impaired orthostatic blood pressure (BP) stabilization, initial orthostatic hypotension, and orthostatic hypotension based on beat-to-beat blood pressure methods in a population-representative sample.
Methods and Results—
Participants were recruited from a nationally representative cohort study (≥50 years). Beat-to-beat systolic BP, diastolic BP, and heart rate records were analyzed among those who underwent an active stand test (n=4475). Normograms were estimated by use of generalized additive models for location, shape, and scale with Box-Cox power exponential distribution. Prevalence estimates of impaired BP stabilization, initial orthostatic hypotension, and orthostatic hypotension are reported. Orthostatic BP responses in adults aged 50 to 59 years stabilized within 30 seconds of standing, with older groups taking 30 seconds or longer. The total prevalence of impaired BP stabilization was 15.6% (95% confidence interval [CI], 14.1%–17.1%), increasing with age to 41.2% (95% CI, 30.0%–52.4%) in people ≥80 years old. Initial orthostatic hypotension occurred in 32.9% (95% CI, 31.2%–34.6%) of the population aged ≥50 years, with no age gradient evident. The prevalence of orthostatic hypotension was 6.9% (95% CI, 5.9%–7.8%) in the total population, increasing to 18.5% (95% CI, 9.0%–28.0%) in those aged ≥80 years old.
Conclusions—
Significant age-related differences exist in the time course of postural BP responses, with abnormal responses taking longer than 30 seconds to stabilize. Impaired BP stabilization is more common as we age, affecting more than two-fifths of the population aged ≥80 years, and may play a future role in the management of falls and syncope.
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Affiliation(s)
- Ciarán Finucane
- From The Irish Longitudinal Study on Ageing (TILDA), Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland (C.F., M.D.L. O., H.N., H.C., R.A.K.); Department of Medical Physics and Bioengineering, St. James’s Hospital, Dublin, Ireland (C.F., C.J.S.); Department of Medical Gerontology, Mater Hospital, Dublin, Ireland (C.W.F.); and School of Health Sciences, University of East Anglia, Norwich, United Kingdom (G.M.S.)
| | - Matthew D.L. O’Connell
- From The Irish Longitudinal Study on Ageing (TILDA), Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland (C.F., M.D.L. O., H.N., H.C., R.A.K.); Department of Medical Physics and Bioengineering, St. James’s Hospital, Dublin, Ireland (C.F., C.J.S.); Department of Medical Gerontology, Mater Hospital, Dublin, Ireland (C.W.F.); and School of Health Sciences, University of East Anglia, Norwich, United Kingdom (G.M.S.)
| | - Chie Wei Fan
- From The Irish Longitudinal Study on Ageing (TILDA), Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland (C.F., M.D.L. O., H.N., H.C., R.A.K.); Department of Medical Physics and Bioengineering, St. James’s Hospital, Dublin, Ireland (C.F., C.J.S.); Department of Medical Gerontology, Mater Hospital, Dublin, Ireland (C.W.F.); and School of Health Sciences, University of East Anglia, Norwich, United Kingdom (G.M.S.)
| | - George M. Savva
- From The Irish Longitudinal Study on Ageing (TILDA), Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland (C.F., M.D.L. O., H.N., H.C., R.A.K.); Department of Medical Physics and Bioengineering, St. James’s Hospital, Dublin, Ireland (C.F., C.J.S.); Department of Medical Gerontology, Mater Hospital, Dublin, Ireland (C.W.F.); and School of Health Sciences, University of East Anglia, Norwich, United Kingdom (G.M.S.)
| | - Christopher J. Soraghan
- From The Irish Longitudinal Study on Ageing (TILDA), Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland (C.F., M.D.L. O., H.N., H.C., R.A.K.); Department of Medical Physics and Bioengineering, St. James’s Hospital, Dublin, Ireland (C.F., C.J.S.); Department of Medical Gerontology, Mater Hospital, Dublin, Ireland (C.W.F.); and School of Health Sciences, University of East Anglia, Norwich, United Kingdom (G.M.S.)
| | - Hugh Nolan
- From The Irish Longitudinal Study on Ageing (TILDA), Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland (C.F., M.D.L. O., H.N., H.C., R.A.K.); Department of Medical Physics and Bioengineering, St. James’s Hospital, Dublin, Ireland (C.F., C.J.S.); Department of Medical Gerontology, Mater Hospital, Dublin, Ireland (C.W.F.); and School of Health Sciences, University of East Anglia, Norwich, United Kingdom (G.M.S.)
| | - Hilary Cronin
- From The Irish Longitudinal Study on Ageing (TILDA), Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland (C.F., M.D.L. O., H.N., H.C., R.A.K.); Department of Medical Physics and Bioengineering, St. James’s Hospital, Dublin, Ireland (C.F., C.J.S.); Department of Medical Gerontology, Mater Hospital, Dublin, Ireland (C.W.F.); and School of Health Sciences, University of East Anglia, Norwich, United Kingdom (G.M.S.)
| | - Rose Anne Kenny
- From The Irish Longitudinal Study on Ageing (TILDA), Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland (C.F., M.D.L. O., H.N., H.C., R.A.K.); Department of Medical Physics and Bioengineering, St. James’s Hospital, Dublin, Ireland (C.F., C.J.S.); Department of Medical Gerontology, Mater Hospital, Dublin, Ireland (C.W.F.); and School of Health Sciences, University of East Anglia, Norwich, United Kingdom (G.M.S.)
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27
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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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Providência R, Candeias R, Morais C, Reis H, Elvas L, Sanfins V, Farinha S, Eggington S, Tsintzos S. Financial impact of adopting implantable loop recorder diagnostic for unexplained syncope compared with conventional diagnostic pathway in Portugal. BMC Cardiovasc Disord 2014; 14:63. [PMID: 24884560 PMCID: PMC4101834 DOI: 10.1186/1471-2261-14-63] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 04/28/2014] [Indexed: 11/20/2022] Open
Abstract
Background To estimate the short- and long-term financial impact of early referral for implantable loop recorder diagnostic (ILR) versus conventional diagnostic pathway (CDP) in the management of unexplained syncope (US) in the Portuguese National Health Service (PNHS). Methods A Markov model was developed to estimate the expected number of hospital admissions due to US and its respective financial impact in patients implanted with ILR versus CDP. The average cost of a syncope episode admission was estimated based on Portuguese cost data and landmark papers. The financial impact of ILR adoption was estimated for a total of 197 patients with US, based on the number of syncope admissions per year in the PNHS. Sensitivity analysis was performed to take into account the effect of uncertainty in the input parameters (hazard ratio of death; number of syncope events per year; probabilities and unit costs of each diagnostic test; probability of trauma and yield of diagnosis) over three-year and lifetime horizons. Results The average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Over a lifetime horizon, the total discounted costs of hospital admissions and syncope diagnosis for the entire cohort were 23% lower amongst patients in the ILR group compared with the CDP group (1,204,621€ for ILR, versus 1,571,332€ for CDP). Conclusion The utilization of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. The result is robust to changes in the input parameter values, and cost savings become more pronounced over time.
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Affiliation(s)
- Rui Providência
- Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra, Portugal.
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Dipaola F, Costantino G, Solbiati M, Barbic F, Capitanio C, Tobaldini E, Brunetta E, Zamunér AR, Furlan R. Syncope risk stratification in the ED. Auton Neurosci 2014; 184:17-23. [PMID: 24811585 DOI: 10.1016/j.autneu.2014.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 03/29/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Abstract
Syncope may be the final common presentation of a number of clinical conditions spanning benign (i.e. neurally-mediated syncope) to life-threatening diseases (i.e. cardiac syncope). Hospitalization rate after a syncopal episode is high. An effective risk stratification is crucial to identify patients at risk of poor prognosis in the short term period to avoid unnecessary hospital admissions. The decision to admit or discharge a syncope patient from the ED is often based on the physician's clinical judgment. In recent years, several prognostic tools (i.e. clinical prediction rules and risk scores) have been developed to provide emergency physicians with accurate guidelines for hospital admission. At present, there are no compelling evidence that prognostic tools perform better than physician's clinical judgment in assessing the short-term outcome of syncope. However, the risk factors characterizing clinical prediction rules and risk scores may be profitably used by emergency doctors in their decision making, specifically whenever a syncope patient has to be discharged from ED or admitted to hospital. Patients with syncope of undetermined etiology, who are characterized by an intermediate-high risk profile after the initial evaluation, should be monitored in the ED. Indeed, data suggest that the 48h following syncope are at the highest risk for major adverse events. A new tool for syncope management is represented by the Syncope Unit in the ED or in an outpatient setting. Syncope Unit may reduce hospitalization and length of hospital stay. However, further studies are needed to clarify whether syncope patients' prognosis can be also improved.
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Affiliation(s)
- Franca Dipaola
- Internal Medicine, Department of Medical Biotechnologies and Translational Medicine, Humanitas Clinical and Research Center, Rozzano, University of Milan, Italy.
| | - Giorgio Costantino
- Medicina ad Indirizzo Fisiopatologico, Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Ospedale "L. Sacco", Milan, University of Milan, Italy
| | - Monica Solbiati
- Medicina ad Indirizzo Fisiopatologico, Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Ospedale "L. Sacco", Milan, University of Milan, Italy
| | - Franca Barbic
- Internal Medicine, Department of Medical Biotechnologies and Translational Medicine, Humanitas Clinical and Research Center, Rozzano, University of Milan, Italy
| | - Chiara Capitanio
- Internal Medicine, Department of Medical Biotechnologies and Translational Medicine, Humanitas Clinical and Research Center, Rozzano, University of Milan, Italy
| | - Eleonora Tobaldini
- Medicina ad Indirizzo Fisiopatologico, Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Ospedale "L. Sacco", Milan, University of Milan, Italy
| | - Enrico Brunetta
- Internal Medicine, Department of Medical Biotechnologies and Translational Medicine, Humanitas Clinical and Research Center, Rozzano, University of Milan, Italy
| | - Antonio Roberto Zamunér
- Internal Medicine, Department of Medical Biotechnologies and Translational Medicine, Humanitas Clinical and Research Center, Rozzano, University of Milan, Italy; Department of Physical Therapy, Federal University of Sao Carlos, Brazil
| | - Raffaello Furlan
- Internal Medicine, Department of Medical Biotechnologies and Translational Medicine, Humanitas Clinical and Research Center, Rozzano, University of Milan, Italy
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Sun BC, McCreath H, Liang LJ, Bohan S, Baugh C, Ragsdale L, Henderson SO, Clark C, Bastani A, Keeler E, An R, Mangione CM. Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission. Ann Emerg Med 2013; 64:167-75. [PMID: 24239341 DOI: 10.1016/j.annemergmed.2013.10.029] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/16/2013] [Accepted: 10/24/2013] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes. METHODS This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction. RESULTS Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction. CONCLUSION An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.
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Affiliation(s)
- Benjamin C Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR.
| | - Heather McCreath
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Li-Jung Liang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Stephen Bohan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Christopher Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Luna Ragsdale
- Department of Emergency Medicine, Duke University Medical Center, Durham, NC
| | - Sean O Henderson
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA
| | - Carol Clark
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI
| | | | - Ruopeng An
- College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL
| | - Carol M Mangione
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Fischer LM, Dutra JPP, Mantovani A, de Lima GG, Leiria TLL. Predictors of hospitalization in patients with syncope assisted in specialized cardiology hospital. Arq Bras Cardiol 2013; 101:480-6. [PMID: 24145390 PMCID: PMC4106805 DOI: 10.5935/abc.20130206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 06/28/2013] [Indexed: 11/20/2022] Open
Abstract
Background Risk stratification of a syncopal episode is necessary to better differentiate
patients needing hospitalization of those who can be safely sent home from the
emergency department. Currently there are no strict guidelines from our Brazilian
medical societies to guide the cardiologist that evaluate patients in an emergency
setting. Objectives To analyze the criteria adopted for defining the need for hospitalization and
compare them with the predictors of high risk for adverse outcome defined by the
OESIL score that is already validated in the medical literature for assessing
syncope. Methods A cross-sectional study of patients diagnosed with syncope during emergency
department evaluation at our institution in the year 2011. Results Of the 46,476 emergency visits made in that year, 216 were due to syncope. Of the
216 patients analyzed, 39% were hospitalized. The variables associated with the
need of hospital admission were - having health care insurance, previous known
cardiovascular disease, no history of prior stroke, previous syncope and abnormal
electrocardiograms during the presentation. Patients classified in OESIL scores of
0-1 had a greater chance of emergency discharge; 2-3 scores showed greater
association with the need of hospitalization. A score ≥ 2 OESIL provided an odds
ratio 7.8 times higher for hospitalization compared to score 0 (p <0.001, 95%
CI:4,03-15,11). In approximately 39% no etiological cause for syncope was found
and in 18% cardiac cause was identified. Conclusions Factors such as cardiovascular disease, prior history of syncope, health
insurance, no previous stroke and abnormal electrocardiograms, were the criteria
used by doctors to indicate hospital admission. There was a good correlation
between the clinical judgment and the OESIL criteria for high risk described in
literature.
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Affiliation(s)
- Leonardo Marques Fischer
- Instituto de Cardiologia, Fundação Universitária de Cardiologia do Rio
Grande do Sul, Porto Alegre, RS - Brazil
| | - João Pedro Passos Dutra
- Instituto de Cardiologia, Fundação Universitária de Cardiologia do Rio
Grande do Sul, Porto Alegre, RS - Brazil
| | - Augusto Mantovani
- UFCSPA - Universidade Federal de Ciências da Saúde de Porto Alegre,
Porto Alegre, RS - Brazil
| | - Gustavo Glotz de Lima
- Instituto de Cardiologia, Fundação Universitária de Cardiologia do Rio
Grande do Sul, Porto Alegre, RS - Brazil
- UFCSPA - Universidade Federal de Ciências da Saúde de Porto Alegre,
Porto Alegre, RS - Brazil
| | - Tiago Luiz Luz Leiria
- Instituto de Cardiologia, Fundação Universitária de Cardiologia do Rio
Grande do Sul, Porto Alegre, RS - Brazil
- Mailing Address: Tiago Luiz Luz Leiria, Felix da Cunha, 1010, apt.º 601,
Floresta. Postal Code 90570-000, Porto Alegre, RS - Brazil. E-mail:
,
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Ungar A, Rafanelli M, Cellai T, Ceccofiglio A, Del Rosso A, Mussi C, Marchionni N. Poor diagnostic performance of tilt testing in hypertensive patients with unexplained syncope. J Hum Hypertens 2013; 28:259-62. [PMID: 24132139 DOI: 10.1038/jhh.2013.95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 08/29/2013] [Accepted: 08/30/2013] [Indexed: 11/09/2022]
Abstract
Syncope is a common condition. Tilt testing with sublingual nitroglycerin (TT-TNT) provides a test with good specificity and positivity rate in young and old patients. Its use in hypertensive patients with unexplained syncope has not been validated. The aims of this study were to evaluate the positivity rate, specificity and tolerability of TT-TNT in hypertensive patients with unexplained syncope. Five hundred and ten subjects (mean age 55 years) were enrolled, 388 patients with unexplained syncope (73 hypertensive and 315 normotensive) and 122 controls (59 hypertensive and 63 normotensive). All subjects underwent TT-TNT. The responses were classified as positive, negative or exaggerated (aspecific). In hypertensive patients, the usual hypotensive therapy was taken on the day of the test. In hypertensive controls, the positive responses were higher than in normotensives (19% vs 6%, P<0.001). The overall specificity was 81% in hypertensives and 94% in normotensives. The positivity rate was significantly lower in hypertensives (55% vs 72%, P<0.03). There was no significant difference between young patients and patients >65 years. TT was well tolerated, and no serious side effects occurred. TT potentiated with TNT has a lower positivity rate and specificity in hypertensive than in normotensive patients with syncope.
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Affiliation(s)
- A Ungar
- 1] Syncope Unit, Cardiology and Geriatric Medicine, University of Florence, Florence, Italy [2] Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - M Rafanelli
- 1] Syncope Unit, Cardiology and Geriatric Medicine, University of Florence, Florence, Italy [2] Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - T Cellai
- 1] Syncope Unit, Cardiology and Geriatric Medicine, University of Florence, Florence, Italy [2] Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - A Ceccofiglio
- 1] Syncope Unit, Cardiology and Geriatric Medicine, University of Florence, Florence, Italy [2] Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - A Del Rosso
- Division of Cardiology, Ospedale San Giuseppe, Empoli, Italy
| | - C Mussi
- Geriatric and Gerontology Institute, University of Modena, Modena, Italy
| | - N Marchionni
- 1] Syncope Unit, Cardiology and Geriatric Medicine, University of Florence, Florence, Italy [2] Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Sousa P, Marques N, Faria R, Trigo J, Chin J, Amado J, Pereira S, Candeias R, de Jesus I. [Syncope unit: experience of a center using diagnostic flowcharts for syncope of uncertain etiology after initial assessment]. Rev Port Cardiol 2013; 32:581-91. [PMID: 23827416 DOI: 10.1016/j.repc.2012.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 10/29/2012] [Accepted: 10/31/2012] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Syncope is a common symptom that leads to 1% of admissions to hospital emergency departments, and is associated with high costs to the health system. The cardiology department of Faro Hospital has had a syncope unit since July 2007. The aim of this study is to analyze its results in terms of etiological diagnosis and treatment of syncope, using diagnostic flowcharts based on European Society of Cardiology (ESC) guidelines. METHODS We conducted a retrospective study of all patients referred to the syncope unit of Faro Hospital between July 2007 and August 2011. We analyzed demographic data, characteristics of syncopal episodes, diagnostic methods, etiology of syncope and treatment. The percentages of syncope of cardiac and uncertain etiology were compared with data from other international syncope units. Statistical analysis was performed using SPSS version 13.0. RESULTS Of the 304 patients referred to the syncope unit for loss of consciousness, 245 (80.7%) had syncope. Most had reflex syncope (52.2%), 20% had cardiac syncope, 15.6% had orthostatic hypotension, and in 12% of cases etiology remained undetermined. The percentages of cardiac and uncertain etiology were similar to data published by other syncope units. CONCLUSIONS The Faro Hospital syncope unit obtained similar results to those published by other international syncope units through application of diagnostic flowcharts for etiological diagnosis of syncope. The flowcharts presented can be of value for the proper application of ESC guidelines on syncope.
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Affiliation(s)
- Pedro Sousa
- Serviço de Cardiologia, Hospital de Faro, E.P.E., Faro, Portugal.
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Sousa P, Marques N, Faria R, Trigo J, Chin J, Amado J, Pereira S, Candeias R, de Jesus I. Syncope unit: Experience of a center using diagnostic flowcharts for syncope of uncertain etiology after initial assessment. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Affiliation(s)
- Pradyot Saklani
- University of Western Ontario, Arrhythmia Service, Division of Cardiology, London, Ontario, Canada
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Abstract
Syncope is a major healthcare problem with significant morbidity, mortality and healthcare cost. It is a common symptom with a complex pathophysiology and, therefore, several aetiologies. Tilt-table testing (TTT) is an important, yet perhaps not widely-used, test that forms part of the management of syncope. We sought to assess the utilisation of this test in our institution for the investigation of patients with syncope, to study the referral patterns and the outcomes and usefulness of the TTT in a real-life setting. We undertook a retrospective study of all the TTT that were performed in our institution between January 2009 and October 2009. Of the 69 patients in which TTT was performed, 14 (20%) presented with presyncope, 24 (35%) with a single episode of syncope and 24 (44%) with multiple episodes. The average age was 57.2 years and 64% were female. Of the total patients, 35 (51%) had an abnormal TTT. Of the patients with normal TTT, four had internal loop recorders and six were referred to other medical specialities. The remaining patients (49%) had no formal diagnosis and were referred back to their general practitioner. TTT remains a common test modality and has great value when undertaken in the correct clinical context. This underlines the importance of a detailed clinical history. The European Society of Cardiology guidelines ensure a methodical and rational approach to syncopal patients and aide in choosing the right patient for the right test.
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Affiliation(s)
| | - Pervez Khan
- Goodhope Hospital, Sutton Coldfield, West Midlands, UK
| | - John Panting
- Goodhope Hospital, Sutton Coldfield, West Midlands, UK
| | - Sunil Nadar
- Goodhope Hospital, Sutton Coldfield, West Midlands, UK
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Abstract
Syncope, a clinical syndrome, has many potential causes. The prognosis of a patient experiencing syncope varies from benign outcome to increased risk of mortality or sudden death, determined by the etiology of syncope and the presence of underlying disease. Because a definitive diagnosis often cannot be established immediately, hospital admission is frequently recommended as the "default" approach to ensure patient's safety and an expedited evaluation. Hospital care is costly while no studies have shown that clinical outcomes are improved by the in-patient practice approach. The syncope unit is an evolving practice model based on the hypothesis that a multidisciplinary team of physicians and allied staff with expertise in syncope management, working together and equipped with standard clinical tools could improve clinical outcomes. Preliminary data have demonstrated that a specialized syncope unit can improve diagnosis in a timely manner, reduce hospital admission and decrease the use of unnecessary diagnostic tests. In this review, models of syncope units in the emergency department, hospital and outpatient clinics from different practices in different countries are discussed. Similarities and differences of these syncope units are compared. Outcomes and endpoints from these studies are summarized. Developing a syncope unit with a standardized protocol applicable to most practice settings would be an ultimate goal for clinicians and investigators who have interest, expertise, and commitment to improve care for this large patient population.
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Berdagué P, Vergnes C, Rivallo M, Ducreux B, Pinaton S, Rossocello V, Diarra T, Fournier PY, Azoury N, Hadid M, Sedighian S, Georger F, Romieu M, Reny JL. [Practical implementation and usefulness of guidelines for the management of syncope: a professional practice study]. Ann Cardiol Angeiol (Paris) 2012; 61:345-51. [PMID: 23062605 DOI: 10.1016/j.ancard.2012.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022]
Abstract
AIMS To assess the practical implementation of international guidelines and their impact on syncope management in a 500-bed general hospital. PATIENTS AND METHODS Three groups of 63 consecutive patients admitted for syncope to the emergency care unit (ECU) were studied: group 1, before the guidelines delivered to the practitioners, group 2 immediately after the diffusion of guidelines and group 3, one year later. The study evaluates the mean duration of stay (MDS) and the relevance of the diagnostic strategy. RESULTS In group 1 compared to group 2, MDS were respectively 6.8±5.5 and 5.4±2.8 days (P=0.07) and the unexplained syncope number respectively 22% and 24% (P=0.8). The search of orthostatic hypotension became more systematic (13% versus 86% in group 1 and 2 respectively, P<0.001). The agreement (kappa coefficient) between initial and final diagnostic increased in 0.34 to 0.44. One year later MDS in group 3 was 7.1±4.7 days (P=0.8 versus group 1 and P=0.015 versus group 2) with only 6.3% systematic search for orthostatic hypotension (P<0.001). CONCLUSIONS Guidelines optimize the syncope management in the ECU and the agreement between the emergency and discharge diagnostic without change of unexplained syncope and. MDS tend to be shorter when guidelines are actively implemented. Nevertheless, the positive impact of guidelines implementation is of limited duration.
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Affiliation(s)
- P Berdagué
- Département neurocardiovasculaire, centre hospitalier de Béziers, rue Valentin-Haüy, 34500 Béziers, France.
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Derose SF, Gabayan GZ, Chiu VY, Sun BC. Patterns and preexisting risk factors of 30-day mortality after a primary discharge diagnosis of syncope or near syncope. Acad Emerg Med 2012; 19:488-96. [PMID: 22594351 DOI: 10.1111/j.1553-2712.2012.01336.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The risk of short-term mortality after an emergency department (ED) visit for syncope is poorly understood, resulting in prognostic uncertainty and frequent hospital admission. The authors determined patterns and risk factors for short-term mortality after a diagnosis of syncope or near syncope to aid in medical decision-making. METHODS A retrospective cohort study was performed of adult members of Kaiser Permanente Southern California seen at 11 EDs from 2002 to 2006 with a primary discharge diagnosis of syncope or near syncope (International Classification of Diseases, Ninth Revision [ICD-9] 780.2). The outcome was 30-day mortality. Proportional hazards time-to-event regression models were used to identify risk factors. RESULTS There were 22,189 participants with 23,951 ED visits, resulting in 307 deaths by 30 days. A relatively lower risk of death was reached within 2 weeks for ages 18 to 59 years, but not until 3 months or more for ages 60 and older. Preexisting comorbidities associated with increased mortality included heart failure (hazard ratio [HR] = 14.3 in ages 18 to 59 years, HR = 3.09 in ages 60 to 79 years, HR = 2.34 in ages 80 years plus; all p < 0.001), diabetes (HR = 1.49, p = 0.002), seizure (HR = 1.65, p = 0.016), and dementia (HR = 1.41, p = 0.034). If the index visit followed one or more visits for syncope in the previous 30 days, it was associated with increased mortality (HR = 1.86, p = 0.024). Absolute risk of death at 30 days was under 0.2% in those under 60 years without heart failure and more than 2.5% across all ages in those with heart failure. CONCLUSIONS The low risk of death after an ED visit for syncope or near syncope in patients younger than 60 years old without heart failure may be helpful when deciding who to admit for inpatient evaluation. The presence of one or more comorbidities that predict death and a prior visit for syncope should be considered in clinical decisions and risk stratification tools for patients with syncope. Close clinical follow-up seems advisable in patients 60 years and older due to a prolonged risk of death.
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Affiliation(s)
- Stephen F Derose
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
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Sheldon RS, Morillo CA, Krahn AD, O'Neill B, Thiruganasambandamoorthy V, Parkash R, Talajic M, Tu JV, Seifer C, Johnstone D, Leather R. Standardized Approaches to the Investigation of Syncope: Canadian Cardiovascular Society Position Paper. Can J Cardiol 2011; 27:246-53. [DOI: 10.1016/j.cjca.2010.11.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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McCarthy F, De Bhladraithe S, Rice C, McMahon CG, Geary U, Plunkett PK, Crean P, Murphy R, Foley B, Mulvihill N, Kenny RA, Cunningham CJ. Resource utilisation for syncope presenting to an acute hospital Emergency Department. Ir J Med Sci 2010; 179:551-5. [PMID: 20552293 DOI: 10.1007/s11845-010-0497-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 05/04/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Syncope is a common clinical problem accounting for up to 6% of hospital admissions. Little is known about resource utilisation for patients admitted for syncope management in Ireland. AIM To determine the utilisation of resources for patients admitted for syncope management. METHODS Single centre observational case series of consecutive adult patients presenting to an acute hospital Emergency Department with syncope over a 5-month period. RESULTS Two-hundred and fourteen of 18,898 patients (1.1%) had a syncopal episode, 110 (51.4%) of whom were admitted. Mean length of stay was 6.9 days. Sixty-four of these admissions were deemed unnecessary by retrospective review when compared to ESC guidelines. Eighty-five (77.3%) admitted patients had cardiac investigations and 56 (51%) had brain imaging performed. CONCLUSIONS Syncope places a large demand on overstretched hospital resources. Most cases can be managed safely as an outpatient and to facilitate this, hospitals should develop outpatient Syncope Management Units.
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Affiliation(s)
- F McCarthy
- Department of Medicine for the Elderly, St James's Hospital, James's Street, Dublin, Ireland.
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Plasek J, Doupal V, Fürstova J, Martinek A. THE EGSYS AND OESIL RISK SCORES FOR CLASSIFICATION OF CARDIAC ETIOLOGY OF SYNCOPE: COMPARISON, REVALUATION, AND CLINICAL IMPLICATIONS. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2010; 154:169-73. [DOI: 10.5507/bp.2010.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Vardas PE, Simantirakis EN. Transient loss of consciousness: an ongoing challenge. Europace 2010; 12:774-5. [DOI: 10.1093/europace/euq139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Romero-Rodríguez N, Barón-Esquivias G, Gómez-Moreno S, Arjona Barrionuevo JDD, Pedrote A, Martínez Martínez A. Evaluación del síncope de alto riesgo remitido desde el Servicio de Urgencias. Rev Clin Esp 2010; 210:70-4. [DOI: 10.1016/j.rce.2009.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Accepted: 05/18/2009] [Indexed: 11/28/2022]
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Kulakowski P, Lelonek M, Krynski T, Bacior B, Kowalczyk J, Malkowska B, Tokarczyk M, Stypula P, Pawlik T, Stec SM. Prospective evaluation of diagnostic work-up in syncope patients: results of the PL-US registry. Europace 2009; 12:230-9. [DOI: 10.1093/europace/eup367] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, Deharo JC, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Ruiz Granell R, Sarasin F, Ungar A, van Dijk JG, Walma EP, Wieling W. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631-71. [PMID: 19713422 DOI: 10.1093/eurheartj/ehp298] [Citation(s) in RCA: 1202] [Impact Index Per Article: 80.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Syncope prevalence in the ED compared to general practice and population: a strong selection process. Am J Emerg Med 2009; 27:271-9. [PMID: 19328369 DOI: 10.1016/j.ajem.2008.02.022] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 02/12/2008] [Accepted: 02/14/2008] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE We assessed the prevalence and distribution of the different causes of transient loss of consciousness (TLOC) in the emergency department (ED) and chest pain unit (CPU) and estimated the proportion of persons with syncope in the general population who seek medical attention from either their general practitioner or the ED/CPU. METHODS A review of the charts of consecutive patients presenting with TLOC at the ED/CPU of our university hospital between 2000 and 2002 was conducted. Patients younger than 12 years or with a known epileptic disorder were excluded. Age and sex of syncopal patients were compared with those in a general practice and general population data sets. MAIN FINDINGS AND CONCLUSIONS During the study period, 0.94% of the patients visiting the ED/CPU presented with TLOC (n = 672), of which half had syncope. Only a small but probably selected group of all people with syncope visit the ED/CPU.
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