Utility of Chest Radiography in Emergency Department Patients Presenting With Syncope

Matthew L. Wong, MD, MPH; David Chiu, MD; Nathan I Shapiro, MD, MPH; Shamai A Grossman, MD, MS

Disclosures

Western J Emerg Med. 2016;17(6):698-701. 

In This Article

Abstract and Introduction

Abstract

Introduction: Syncope has myriad etiologies, ranging from benign to immediately life threatening. This frequently leads to over testing. Chest radiographs (CXR) are among these commonly performed tests despite their uncertain diagnostic yield. The objective is to study the distribution of normal and abnormal chest radiographs in patients presenting with syncope, stratified by those who did or did not have an adverse event at 30 days.

Methods: We performed a post-hoc analysis of a prospective cohort of consecutive patients presenting to an urban tertiary care academic medical center with a chief complaint of syncope from 2003–2006. The frequency and findings for each CXR were reviewed, as well as emergency department and hospital discharge diagnoses, and 30-day outcome.

Results: There were 575 total subjects, 39.7% were male, and the mean age was 57.2 (SD 24.6). Of the 575 subjects, 403 (70.1%) had CXRs performed, and 116 (20.2%) had an adverse event after their syncope. Of the 116 people who had an adverse event, 15 (12.9%) had a positive CXR, 81 (69.8%) had a normal CXR, and 20 (17.2%) did not have a CXR as part of the initial evaluation. Among the 459 people who did not have an adverse event, 3 (0.7%) had a positive CXR, 304 (66.2%) had a normal CXR, and 152 (33.1%) did not have a CXR performed. Fifteen of the 18 patients (83.4%) with an abnormal CXR had an adverse event. Eighty-one of the 385 patients (21.0%) with a normal CXR had an adverse event. Among those who had a CXR performed, an abnormal CXR was associated with increased odds of adverse event (OR: 18.77 (95% CI= [5.3–66.4])).

Conclusion: Syncope patients with abnormal CXRs are likely to experience an adverse event, though the majority of CXRs performed in the work up of syncope are normal.

Introduction

Syncope is a common symptom of what is most often a benign disease process, but it may be a marker for a life-threatening illness. Syncope accounts for 740,000 emergency department (ED) visits per year, an estimated 3% of all ED patient visits, of whom 32% get admitted to the hospital. Similarly, up to 50% of patients presenting to the ED with syncope are discharged home from the hospital without an identifying etiology.[1–3] This lack of diagnostic certainty often leads to over testing. Chest radiographs are among these commonly performed tests despite their uncertain diagnostic yield.

The workup for syncope is often confused with the work up of patients with chest pain or myocardial ischemia. Yet, syncope is rarely associated with myocardial ischemia.[4–6] Prior studies have shown that other tests routinely used to evaluate ischemic etiologies of syncope, such as cardiac enzyme testing in syncope, are useful only in patients with concomitant signs and symptoms of cardiac ischemia or an electrocardiogram (EKG) suggestive of a ischemic etiology.[4–6] Similarly, the utility of other cardiac testing in syncope such as echocardiography may be limited to those patients with an audible murmur, a history of valvular disease, or CXR or EKG suggestive of cardiomyopathy.[6] CXR, routinely obtained in most standard cardiac "rule out" protocols as well, has unclear utility in assessing syncope for worrisome etiologies. As such, the objective of this study is to examine the frequency of abnormal CXRs, and begin to determine if CXRs have any diagnostic value.

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