Application of the Recent American Practice Resources for Risk Stratification System for Patients Presenting to a Japanese Emergency Department Because of Syncope

Syncope

Syncope is common representing approximately 3% of ED visits and up to 6% of hospital admissions, with a cost close to 2 billion dollars per year. Diagnostic testing is often poorly sensitive and evaluations commonly lack a standardized approach. A mindful and systematic approach can increase sensitivity and improve diagnostic accuracy. A thorough history and physical exam is paramount, as conclusions drawn from the history and exam will guide further assessment. Developing a strategy for the first and, if necessary, subsequent tests will improve the accuracy of identifying the etiology of syncope and reduce cost. Although syncope has a favorable prognosis, identification of patients with structural heart disease is critical, as these patients are at greatest risk for mortality. Several risk scoring systems have been developed to help separate high risk from low risk patients.

Prognosis among healthy individuals discharged with a primary diagnosis of syncope

OBJECTIVES

This study sought to examine the risk of major cardiac adverse events and death in a nationwide cohort of patients without previous comorbidity admitted for syncope.

BACKGROUND

Syncope is a common clinical event, but knowledge of prognosis is not fully elucidated in healthy individuals.

METHODS

Patients without previous comorbidity admitted for syncope in Denmark from 2001 to 2009 were identified in nationwide administrative registries and matched by sex and age with 5 control subjects from the Danish population. The risk of death or recurrent syncope, implantation of pacemaker or implantable cardioverter-defibrillator, and cardiovascular hospitalization were analyzed with multivariable Cox proportional hazard models.

RESULTS

We identified 37,017 patients with a first-time diagnosis of syncope and 185,085 control subjects; their median age was 47 years (interquartile range, 32 to 63 years) and 47% were male. A total of 3,023 (8.2%) and 14,251 (7.1%) deaths occurred in the syncope and the control population, respectively, yielding an event rate of 14.3 per 1,000 person-years (PY) in the syncope population. Multivariable Cox regression analysis demonstrated a significantly increased risk of all-cause mortality (hazard ratio [HR]: 1.06; 95% confidence interval [CI]: 1.02 to 1.10), cardiovascular hospitalization event rate of 26.5 per 1,000 PY (HR: 1.74; 95% CI: 1.68 to 1.80), recurrent syncope event rate of 45.1 per 1,000, stroke event rate of 6.8 per 1,000 PY (HR: 1.35; 95% CI: 1.27 to 1.44), and pacemaker or implantable cardioverter-defibrillator event rate of 4.2 per 1,000 PY (HR: 5.52; 95% CI: 4.67 to 5.73; p < 0.0001).

CONCLUSIONS

The first admission for syncope among healthy individuals significantly predicts the risk of all-cause mortality, stroke, cardiovascular hospitalization, device implantation, and recurrent syncope.

Fever-induced ST-segment elevation in a syncopal patient with Brugada syndrome

Brugada syndrome (BS) is associated with life-threatening ventricular tachyarrhythmias. Although a diagnosis of BS can be made by typical electrocardiographic (ECG) findings, these findings for BS vary depending on the patients' physiological conditions and are sometimes normalized or less evident. It is important for emergency physicians to recognize that the typical electrocardiographic findings of BS are not always manifested but sometimes are only unmasked in the presence of a specific condition.