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

Discussion

The costs related to syncope-related hospital admissions total over $2 billion per year in the United States, and a large portion of these costs are directly related to diagnostic testing.[1–3] Mendu and others found the yield for testing in syncope to be under 5%, with the exception of orthostatic blood pressure measurements.[8] Whether diagnostic tests, such as chest radiographs, have a similar lack of utility among ED patients with syncope remains unclear.

Abnormal CXRs were observed in 18 of the 575 patients (3.1% overall, or 4.6% of those who had a CXR done), and 385 of the 575 patients (67.0% overall, or 95.5% of those who had a CXR done.) Patients with an abnormal CXR were much more likely to have an adverse event than not (83.4% [60.0%–95.0%] vs. 16.7% [5.0% – 40.1%]), and were at increased odds of having an adverse event compared to the group that had a normal CXR (OR [18.77], 95% CI [5.3–66.4], p<0.01) by Fisher's exact test. All of the abnormal findings were from congestive heart failure, pneumonia, a combination of the two, or pleural effusion (Table 2). The majority of patients, however, either did not have a CXR performed (172/575, 29.9%) or had a normal CXR (385/575, 70.0%). In the subgroup of patients who ultimately had a 30-day adverse event, most CXRs were normal. The patients who did not have a CXR performed appear to be much different than the patients who did have a CXR performed, demonstrated in Table 1, which reflects discretionary physician ordering. But this research is a reflection of clinical practice; when emergency physicians elect to order CXRs, an abnormal CXR is associated with an adverse event. This suggests some modest utility in the CXR in the work up of syncope. An abnormal finding on CXR should inform clinical decision-making as those patients are likely to have an adverse event. We therefore encourage the judicious use of CXRs in the proper clinical scenario.

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