Management of Syncope

Management of Syncope

2016-11-11T18:38:50+00:00

“Done Fell Out”, or DFO, is a common saying in the South to describe syncope. Although the saying is funny the diagnosis is not. Syncope accounts for about 3–5% of ED visits and 1–6% of hospital admissions. In patients >65, syncope is the 6th most common cause of hospitalization.

How do you approach the management of patients with syncope?

Causes of syncope

The most common causes of syncope are: Unknown (34-36%), Vasovagal (18-21%), and Cardiac (9.5-18%). For patients have a history of CV disease, the incidence of cardiac-related syncope also increases (Soteriades et al).
 
Causes of Syncope & The Presence or Absence of CV Disease 
CV Disease
CV Disease Absent 
CV Disease Present 
Sex
Male
Female 
Male
Female
Cardiac Etiology
6.5%
3.8%
26.7%
16.8%
 

Why Does CV Disease Matter?

Bottom Line: Cardiac etiologies of syncope (red line above) have the highest associated mortality!

Do Risk Stratification Tools Work?

There is no “gold standard” evaluation for syncope, but there are several different scores and more coming out every month. Here is a list of several:

These rules are difficult to evaluate in part because of different weights on different variables contributing to the scoring system. A major problem with most of these scoring systems is that older patients are underrepresented. This is an issue because as our patient population gets older so does the incidence of syncope and the incidence of cardiac etiologies.

Bottom Line: Educated clinician judgment based on EBM guidelines (European Society for Cardiology and ACEP) seems to be the best strategy for management. Syncope prediction rules can certainly aid this process, but they do not yet fit for use alone for risk stratification in any population.

  • Older age and associated comorbidities (No set definition) 
  • Abnormal EKG findings (acute ischemia, dysrhythmias, or significant conduction abnormalities) 
  • Hematocrit
  • History or presence of CHF, CAD, or structural heart disease 

Does Everyone with Syncope Need a Head CT?

ACEP’s Level C recommendation states Cranial CT scanning need NOT be routinely performed unless guided by specific findings in the history or physical exam. So what are those findings?

Bottom Line: Clinicians might consider obtaining a Head CT as part of the syncope evaluation for the following findings:

  • Trauma above the clavicle 
  • Persistent neurologic deficit or complaint 
  • Age >65 
  • Sudden onset headache 
  • Patients on warfarin (coumadin)

What about using Syncope Management Units (SMUs)?

Because a definitive diagnosis cannot be established immediately, hospital admission is frequently recommended as the “default” approach to ensure patient’s safety and guarantee an expedited evaluation. The problem with this is the hospital care is expensive, and no studies to date have shown that clinical outcomes are improved by the in-patient practice approach. The concept of the SMU is like a chest pain observation unit. Place syncope patients under observation in the ED, and use a multidisciplinary team of physicians to perform the consultation, echo, telemetry, and other diagnostic tests from the ED.

Below are the findings from the Syncope Evaluation in the Emergency Department Study (SEEDS) study:

 
 

Bottom Line: This is an interesting concept and shows decreased hospital admission. This particular study, however, was poorly powered, unblinded, and had no cost-benefit analysis. A multicenter, multidisciplinary study would need to be performed to externally, validate and standardize the risk stratification scheme and concept of a SMU before implementation.

 

FINAL THOUGHTS on management and disposition

It is our job as emergency physicians to NOT identify a precise cause of syncope. Instead, we should aim to risk-stratify our patients: Who needs to be hospitalized (high risk) versus who can be safely discharge home (low risk) with outpatient follow up? The keys are:

  1. Use clinician judgment aided partly by risk stratification scores. 
  2. Remember ACEP’s recommendations on syncope admissions.

References

  1. Al-Nsoor NM. Brain Computed Tomography in Patients with Syncope. Neurosciences 2010 Apr; 15 (2): 105 – 9. PMID: 20672498
  2. Del Rosso A et al. Clinical Predictors of Cardiac Syncope at Initial Evaluation in Patients Referred Urgently to A General Hosptial: The EGSYS Score. Heart 2008 Dec; 94 (12): 1620 – 6. PMID:18519550
  3. Giglio P et al. Syncope and head CT Scans in the Emergency Department. Emerg radiol 2005 Dec; 12 (1-2): 44 – 6. PMID: 16292675
  4. Goyal N et al. The Utility of Head Computed Tomography in the emergency Department Evaluation of Syncope. Intern Emerg Med 2006; 1 (2): 148 – 50. PMID: 17111790
  5. Grossman SA et al. Reducing Admissions Utilizing the Boston Syncope Criteria. J Emerg Med 2012 Mar; 42 (3): 345 – 52. PMID: 21421292
  6. Grossman SA et al. The Yield of Head Ct in Syncope: A Pilot Study. Intern Emerg Med 2007 Mar; 2 (1): 46 – 9. PMID: 17551685
  7. Huff JS et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope. Ann Emerg Med 2007 Apr; 49 (4): 431 – 44. PMID: 17371707
  8. Numeroso F et al. Syncope in the Emergency Department of a Large Northern Italian Hospital Incidence, Efficacy of a Short-Stay Observation Ward and Validation of the OESIL Risk Score. Emerg Med J 2010 Sep; 27 (9): 653 – 8. PMID: 20515909
  9. Pires LA et al. Diagnostic Paterns and Temproal Trends in the Evaluation of Adult Patients Hospitalized With Syncope. Arch Intern Med 2001 Aug; 161 (15): 1889 – 95. PMID: 11493131
  10. Reed MJ et al. The ROSE (Risk Stratification of Syncope in the Emergency Department) Study. J Am Coll Cardiol 2010 Feb; 55 (8): 713 – 21. PMID: 20170806
  11. Snead GR et al. Can the San Francisco Syncope Rule Predict Short-Term Serious Outcomes in Patients Presenting with Syncope? Ann Emerg Med 2013 Jan. PMID: 23332611
  12. Soteriades ES et al. Incidence and Prognosis of Syncope. NEJM 2002; 347: 878 – 85. PMID: 12239256
  13. Sun BC et al. Predictors of 30-day Serious Events in Older Patients with Syncope. Ann Emerg Med 2009 Dec; 54 (6): 769 – 778. PMID: 19766355

Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor
Clinical Assistant Professor of EM and IM
University of Texas Health Science Center at San Antonio
Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews
  • A difficult diagnostic decision presents with all of these patients. My biggest complaint in the work up of syncope is the people who insist on getting a head CT just because the patient passed out. Not needed! I do feel many of these patients can be discharged home with good outpatient follow up. The problem in my population is getting outpatient follow up.

    • I agree with you Matt, it is not needed 100% of the time. One thing I did not mention in this summary is that orthostatic syncope is 10% of all syncope. That is 1/10 pts. It might be worthwhile to check orthostatics in these patients as well, before d/c home. Thank you for continuing to contribute to the site and #FOAMed.

      Salim

    • Glad to help. Orthostatic is very common. Checking orthostatics is important, but be cautious in the elderly with severe arteriosclerosis. They may not be able to respond appropriately.

  • Anonymous

    thanks for this good review
    maybe amend the table to show which rules are validated/not?
    In my centre we simply cannot admit everyone with syncope. We often consult to cardio who often send the patients home.
    I use the Boston Rule to see if there’s anything I am missing [recognising that it may not be ready for prime time].
    I observe,repeat some tests if need be, document and never let them go with abnormal vitals. I cannot recall the last time I CT’d someone for syncope.
    Nadim

    • Hello Nadim,
      Thank you for taking the time to read this post. Not all of the rules are validated externally, agreed, but they all have the same problem, they do not take older patients into account. So whether validated or not, these rules cannot be applied alone for syncope stratification to the general population. That being said…..here is a link to a great meta-analysis article that discusses that very thing.

      https://umem.org/files/uploads/1202201611_JC3072012A.pdf

      Hopefully answers your question. 🙂 Thank you for bringing up the validation point, this is an important concept to remember when looking at clinical decision rules.

      Salim

  • How are we talking about recording orthostatics? Because I think if we are going to go so far as measuring orthostatics, it should not be number dependent, rather… if we stand up our patient and they subjectively feel lightheaded, weakness, etc, then that is a positive orthostatic value.. I don’t believe in the arbitary number rule. What do you all think?

    • Nikita,
      I always treat the patient and not the numbers. I 100% agree with that statement. I do the same for HTN for that matter. Treat the patient not the numbers. 🙂

      Salim