Welcome to the thirteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

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DISCUSSING:(Click for Open Access Through 4/30/18)

Syncope Prognosis Based on Emergency Department Diagnosis: A Prospective Cohort Study. Cristian Toarta, MD, Muhammad Mukarram, MBBS, MPH, Kirtana Arcot, MSc, Soo-Min Kim, BScH, Sarah Gaudet, RN, Marco L. A. Sivilotti, MD, MSc, Brian H. Rowe, MD, MSc, and Venkatesh Thiruganasambandamoorthy, MBBS, MSc. Academic Emergency Medicine 2018

LISTEN NOW: AUTHOR INTERVIEW

ARTICLE SUMMARY:

Objectives: Patients presenting to emergency departments (EDs) with syncope are given various diagnoses for cause including: vasovagal, orthostatic hypotension, cardiac and unknown. This study aims to determine short-term outcomes in each diagnostic group up to 30 days following the initial ED visit for syncope.

Methods: Adult syncope patients were prospectively enrolled from six Canadian EDs by treating physicians. Syncope was defined as a transient loss of consciousness followed by complete recovery and those with presyncope, persistent mental status changes, seizures, alcohol or drug intoxication or patients with major trauma were excluded. Additionally, patients with serious conditions identified during the initial ED visit were excluded as the study aimed to prognosticate after diagnosis. Patient demographics, ED management, presumed diagnosis at the end of visit and physician confidence in that diagnosis were collected at the time of visit. Serious outcomes, including death, arrhythmias, myocardial infarction, structural heart disease, pulmonary embolism, subarachnoid hemorrhage, serious hemorrhage or other conditions that would require a return visit or intervention were assessed 30 days following the initial visit.

Results: A total of 5,010 patients were included in the final analysis, of whom the cause of syncope was found to be vasovagal in 2,671 (53.3%) unknown in 1,615 (32.2%), orthostatic in 456 (9.1%) and cardiac in 268 (5.4%) of patients. Of all patients, 177 (3.5%) suffered serious outcomes including 15 deaths (0.3%), 115 cardiac (2.3%) and 47 non-cardiac (0.9%) outcomes. No deaths occurred in the vasovagal syncope group. The proportion of serious outcomes was significantly higher in all groups other than vasovagal, increasing in the following order: vasovagal, orthostatic hypotension, unknown and cardiac (p< 0.01). The proportion of patients among whom diagnostic testing was performed also increased in the same order with least in vasovagal and most in cardiac syncope (p< 0.001), with 42.9% of those with cardiac syncope hospitalized compared to 9.4% overall. The physician confidence in assigning a diagnosis was highest in the vasovagal syncope group and lowest in the unknown syncope group. 

Conclusions: Physician diagnosis strongly correlated with probability of serious outcomes in patients with syncope. This initial diagnosis with physician clinical judgment could be factored into future scores for risk stratification and management of patients with syncope.

FURTHER READING:

 1. Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2016;188(12):E289-298

 2. Thiruganasambandamoorthy V, Stiell IG, Sivilotti ML, et al. Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study. BMC Emergency Medicine. 2014;14:8.

3. Costantino G, Casazza G, Reed M, et al. Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis. The American Journal of Medicine. 2014;127(11):1126.e1113-1125.

4. Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Annals of Emergency Medicine. 2004;43(2):224-232.