Author + information
- Published online November 29, 2017.
- Anil K. Gehi, MD∗ ( and )
- Venkata Narla, MD
- Division of Cardiology, Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
- ↵∗Address for correspondence:
Dr. Anil K. Gehi, Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, 160 Dental Circle, CB 7075, Chapel Hill, North Carolina 27599.
Syncope is a symptom with many causes ranging from benign to potentially life threatening. Although most causes of syncope are benign, it can be a harbinger of sudden death in a small subset of patients. Cardiac causes of syncope have a poorer prognosis than other forms of syncope. Thus, identification of the cause of syncope and risk stratification in the emergency department, the hospital, and the outpatient setting are imperative but can be inherently challenging (1). When the diagnosis is unclear, studies used to evaluate the potential cause of syncope have a low diagnostic yield (2). However, given the consequences of a missed malignant diagnosis, providers often resort to performing a multitude of diagnostic tests. Such evaluation may include laboratory tests, tilt table test, cardiac monitoring, stress test, cardiac or noncardiac imaging, electroencephalography, or electrophysiology (EP) study. Unfortunately, even with exhaustive evaluation, the cause of syncope can remain elusive in a significant proportion of patients. Because syncope is a common occurrence with lifetime risk as high as 40% and recurrent episodes occurring in as many as 14% of patients (3), the evaluation of syncope is a significant burden on our health care system (4,5).
In this issue of JACC: Clinical Electrophysiology, Sandhu et al. (6) evaluated the impact of visits to the emergency department (ED) for syncope on health care in Alberta, Canada. The authors evaluated outcomes of over 50,000 patients who presented to the ED over an 8-year period. Patients were divided into cohorts of patients who were hospitalized with a primary diagnosis of syncope (cohort 1), those who were hospitalized with a primary diagnosis other than syncope (cohort 2), and those discharged home from the ED with a primary diagnosis of syncope (cohort 3). Measured outcomes included 30-day ED revisits for syncope, readmission rates, short- and long-term mortality, and total cost for syncope presentations. Subsequent evaluation and management, which was tracked and included in the cost analysis, included hospitalizations, device implantation, brain imaging, EP testing, and medical therapy. Overall, the authors found that 6.6% were hospitalized and discharged with a primary diagnosis of syncope (cohort 1), 8.7% were hospitalized and discharged with a diagnosis other than syncope (cohort 2), and the remaining 84.7% were discharged home with a diagnosis of syncope (cohort 3). Mortality was highest for cohort 2. Costs of care were substantial, totaling $534.8 million, including $29,940/patient for cohort 1, $42,558/patient for cohort 2, and $10,266/patient for cohort 3.
Important findings of this study included: 1) most patients presenting to the ED with a primary diagnosis of syncope in Alberta, Canada, were considered to be at low risk and were discharged; 2) repeated 30-day ED visits and hospitalizations were low, but by 1 year, costs approached 5% to 8%; 3) mortality was extremely low among those discharged from the ED, and overall mortality in the total cohort was driven mostly by the burden of comorbidities; 4) costs of care were lowest per patient for those discharged from the ED, but total costs were highest among this same cohort because they accounted for the majority of the total ED syncope population.
There are some limitations of this study which should be noted. First, it was presumed that the decision to discharge patients was made at the discretion of the ED physicians and was not prescribed by any particular practice guideline or algorithm. It is likely that the relative proportions of the different cohorts seen here may be quite different at other centers, as determined by the local patient population and practice patterns. Second, although costs of care incurred subsequent to the ED visit, such as those for device implantation, brain imaging, EP study, and medical therapy, were included in the cost analyses, these may not have been exhaustive. For example, it is unclear whether the authors included costs of cardiac monitoring or cardiac imaging (echocardiography, stress testing), which are frequently performed in syncope evaluations. Furthermore, data for the diagnostic yield of these studies are not shown. Third, the authors were unable to provide the distribution of various tests performed as well as the cost breakdown analysis for each type of test performed, which could facilitate cost reduction strategies. However, they do report that hospitalizations accounted for a large proportion of total costs, and therefore, strategies aimed at reducing admission rates could potentially lead to a significant decrease in total costs for syncope evaluation.
Nevertheless, to help understand the scope of the syncope predicament, Sandhu et al. (6) have provided a modern assessment of costs of care for ED presentations of syncope and included some of the costs incurred beyond the ED presentation. The study helps lay the groundwork for an effort to develop more rigorous protocols of care to improve diagnostic yield and to reign in the health care costs, for example, by moving toward a value-based model for care delivery.
The recently published American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines for the evaluation and management of patients with syncope provide the framework for the development of such care protocols (4). Initial evaluation should be based only on a detailed history, physical examination, and electrocardiography (ECG) study. The cause of syncope is often clear with this limited evaluation, and no further testing, ED evaluation, or hospitalization is necessary. However, those with an unclear diagnosis should undergo targeted testing based on initial evaluation. The decision to hospitalize should be based on the presence of serious medical conditions or a schematic of risk stratification, several of which have been rigorously analyzed (7,8). A structured ED observation protocol could be used for those at intermediate risk or who could have further expedited evaluation performed. The yield of diagnostic tests such as brain or carotid imaging or routine electroencephalography is minimal (2). Cardiac monitoring in the inpatient setting is of low diagnostic yield in the absence of an abnormal baseline ECG or other high suspicion for arrhythmic syncope (9). However, ambulatory cardiac monitoring tailored to the frequency and nature of syncope has a high diagnostic yield and could certainly be initiated in the ED (10–12).
Conclusions and Future Considerations
Moving forward, it is imperative that future studies evaluate the impact of cogent management protocols for syncope in comparison with that of routine care practices that are often unstructured in approach.
Outcomes should include mortality, hospitalizations, ED visits, and costs of care, including diagnostic evaluation performed after the initial presentation. As evident from the study by Sandhu et al. (6), a large proportion of the total costs of care for syncope presentations is due to potentially unnecessary ED visits and unnecessary diagnostic evaluations.
Efficient and effective protocols for care should be developed with the acknowledgement that: 1) a minimalist evaluation including detailed history and physical examination with ECG generally provides the highest diagnostic yield or guides further testing (4); 2) syncope with a clear diagnosis needs no further diagnostic evaluation; 3) low-risk syncope patients rarely benefit from ED visits much less hospitalization (13,14); 4) cardiac syncope should prompt targeted cardiac evaluation; 5) cardiac monitoring has a high diagnostic yield and can be performed best on an outpatient basis; 6) a multidisciplinary approach to syncope could improve use of health care resources (6,15). An example of a protocol for care is shown in Figure 1. In developing and evaluating such protocols, consensus must be achieved on best strategies for risk stratification. Methods for streamlining and targeting diagnostic evaluation based primarily on an initial evaluation of history, physical examination, and ECG results will maximize diagnostic yield and should be emphasized. A dedicated syncope management team with both ED and outpatient components including directed patient education will likely best achieve these goals.
↵∗ Editorials published in JACC: Clinical Electrophysiology reflect the views of the authors and do not necessarily represent the views of JACC: Clinical Electrophysiology or the American College of Cardiology.
Dr. Gehi has received research funding from Bristol Myers-Squib Foundation, and has received speakers honoraria from Zoll Inc. and Abbott Inc. Dr. Narla has reported he has no relationships relevant to the contents of this paper to disclose.
All authors attest that they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- 2017 American College of Cardiology Foundation
- Johnson P.C.,
- Ammar H.,
- Zohdy W.,
- et al.
- Shen W.K.,
- Sheldon R.S.,
- Benditt D.G.,
- et al.
- Khera S.,
- Palaniswamy C.,
- Aronow W.S.,
- et al.
- Sandhu R.K.,
- Tran D.T.,
- Sheldon R.S.,
- Kaul P.
- Shen W.K.,
- Decker W.W.,
- Smars P.A.,
- et al.
- David M.
- Krahn A.D.,
- Klein G.J.,
- Yee R.,
- et al.
- Manheimer E.D.,
- Pacio G.,
- Ferrick K.J.