Incidence and predictive factors of acute diseases in patients with syncope: the ESCAPE study

Abstract

According to the 2018 ESC guidelines, emergency physicians shall primarily aim to identify syncopal episodes associated with an underlying acute principal disease. Therefore, in this study, we aimed to assess the incidence of syncope associated with acute principal diseases (APDs) and to identify predictive factors reflecting the presence of these underlying conditions. We retrospectively evaluated all patients presenting with syncope during a 6-month period to the local emergency department, collecting incidence of syncopal cases associated with APDs, personal information, clinical features, and laboratory abnormalities, which were compared between syncopal patients with or without APDs. A syncope-associated APD could be diagnosed in 346/1279 patients (27.1%). In the majority of cases, the cause was a non-cardiovascular acute condition (67%), mostly non-life-threatening such as infectious diseases (34.4%) and acute diseases with pain, fluid loss or hypotension (23.7%). Severe acute cardiovascular conditions were less frequent (4.2%). Cardiogenic syncope, no previous history of syncopal episodes, not full agreement with typical clinical features of syncope, alterations of vital parameters, and laboratory abnormalities were also found to be independently associated with syncope-associated APDs. Syncope may be frequently associated with APDs of varying severity, though mostly non-clinically threatening, thus confirming that this condition shall be considered a symptom and not a disease. Emergency physicians should hence be first engaged in troubleshooting an underlying pathology when facing patients with syncope, for timely identifying patients at higher risk of short-term adverse events and reducing inappropriate admissions and diagnostic investigations, especially in the presence of hypotensive syncope elicited by non-severe concurrent conditions.

Triage assessment of transitory loss of consciousness in the emergency department—A retrospective observational study

“…However, TLOC can also occur during other acute pathological processes (e.g. sepsis, gastrointestinal haemorrhage) that, although not primarily involving the cardiac structure, can rapidly evolve and require medical attention and appropriate therapeutic intervention (Grossman et al, 2012; Numeroso et al, 2021). Some authors who analysed TLOC in the ED have suggested the need to also include in the guidelines acute conditions that are not primarily cardiac that may present with a TLOC as the epiphenomenon of a severe systemic deregulation that needs to be promptly managed in the ED and is probably not observed in the close cardiological setting (e.g.…”

“…First, the retrospective nature of the study exposes it to the possible bias associated with such a study design. Second, the choice of the acute diseases included in the composite outcome of the study was made a priori on the basis of the literature and similar existing studies (Bonzi et al, 2014; Numeroso et al, 2017, 2019, 2021). Third, the accuracy of nurse triage was not assessed through inter‐rater reliability.…”

“…Although the majority of TLOCs are syncopal, a smaller proportion of TLOCs are non‐syncopal (e.g. epilepsy, psychosis; Brignole et al, 2018a; Numeroso et al, 2021; Thiruganasambandamoorthy et al, 2015). Furthermore, even in cases in which syncopal TLOC appears to be caused by a functional condition (e.g.…”

“…Furthermore, even in cases in which syncopal TLOC appears to be caused by a functional condition (e.g. orthostatic hypotension: volume depletion) in the absence of a clear cardiac alteration, there may be an underlying serious pathological condition such as a systemic inflammatory process or gastrointestinal haemorrhage that requires rapid clinical recognition and prompt therapeutic management (Brignole et al, 2018a; Numeroso et al, 2018, 2019, 2021). The European Society of Cardiology (ESC) guidelines have recently clarified the definition of TLOC in relation to syncope and suggested a classification of TLOC according to the possible aetiological mechanism (Brignole et al, 2018a).…”

“…In the complex evaluation of a TLOC, the ED nurses should primarily aim to identify TLOCs that may be the onset or consequence of an underlying severe acute disease (SAD), as such a disease may cause a more severe short‐term event than the TLOC itself (Numeroso et al, 2021). The starting point for a correct classification of TLOC in the ED is triage (Tam et al, 2018).…”