Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients

Abstract

Background Syncopal episodes are common among older adults; etiologies range from benign to life-threatening. We determined the frequency, yield, and costs of tests obtained to evaluate older persons with syncope. We also calculated the cost per test yield and determined whether the San Francisco Syncope Rule (SFSR) improved test yield. Methods Review of 2,106 consecutive patients 65 years and older admitted following a syncopal episode. Results Electrocardiograms (99%), telemetry (95%), cardiac enzymes (95%), and head computed tomography (CT) (63%) were the most frequently obtained tests. Cardiac enzymes, CTs, echocardiograms, carotid ultrasounds, and electroencephalography all affected diagnosis or management in <5% of cases and helped determine etiology of syncope < 2% of the time. Postural blood pressure, performed in only 38% of episodes, had the highest yield with respect to affecting diagnosis (18-26%) or management (25-30%) and determining etiology of the syncopal episode (15-21%). The cost per test affecting diagnosis or management was highest for electroencephalography ($32,973), CT ($24,881), and cardiac enzymes ($22,397) and lowest for postural blood pressure ($17-$20). The yields and costs for cardiac tests were better among patients meeting, than not meeting, SFSR. For example, the cost per cardiac enzymes affecting diagnosis or management was $10,331 in those meeting, versus $111,518 in those not meeting, the SFSR. Conclusions Many unnecessary tests are obtained to evaluate syncope. Selecting tests based on history and examination and prioritizing less expensive and higher yield tests would ensure a more informed and cost-effective approach to evaluating older patients with syncope.

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

“…Occurrence of symptoms correlating with a documented arrhythmia on monitoring is considered a gold standard for the di agnosis of arrhythmia, but asymptomatic findings on monitoring, including asystole >3 seconds, Mobitz 2 atrioventricular block, ventricular arrhythmia, or rapid supraventricular arrhythmias, when associated with syncope at other times, have also been considered di agnostic. 271 In contrast to a 5% diagnostic yield of in patient telemetry monitoring in unselected populations admitted for syncope of undetermined origin, 272 prede termined algorithms based on predictive characteristics documented a 16% to 18% diagnostic yield with inpa tient monitoring. 273,274 In a study of telemetry use, syn cope was one of the major diagnoses for which telem etry monitoring influenced management decisions.…”

Transvenous Stimulation of the Renal Sympathetic Nerves Increases Systemic Blood Pressure: A Potential New Treatment Option for Neurocardiogenic Syncope

“…1, 2 Neurocardiogenic syncope (NCS), the most common cause of syncope, accounts for 20% of new cases of syncope and has a prevalence of 22% in the U.S. population. 3 Current therapies including medications and cardiac pacemaker do not reliably prevent syncope in NCS.…”

Carotid ultrasound is not helpful in simple syncope

“…We found seven papers [5][6][7][8][9][10][11] describing original research which evaluates the use of carotid ultrasound in patients with syncope. All papers were retrospective chart reviews.…”

“…Beyond the retrospective nature of the studies, many of them had other flaws or study characteristics which made the result less applicable to our patient. Many of the studies [6][7][8][9][10][11] did not exclude patients with high-risk history or patients with focal neurological findings. The Vanbrabant study 10 evaluated many different diagnostic tests, and only 23 of their 117 study patients received carotid ultrasound.…”

“…The Vanbrabant study 10 evaluated many different diagnostic tests, and only 23 of their 117 study patients received carotid ultrasound. Some studies 6,8,10,11 evaluated only for diagnostic yield and not for changes in therapy, which was felt to be less patient-oriented. Only the Schnipper study 9 investigated the risk of subsequent syncope or cerebrovascular accident, but only did so in patients who had significant findings on ultrasound.…”