New Syncope Guidelines Take Aim at ED Bottleneck

Patrice Wendling

March 23, 2018

BARCELONA, Spain  — About half of all people will have an episode of syncope in their lifetime, and up until now, an equal number in any part of the world will have been admitted to the hospital, even if risk for recurrence is low.

New 2018 European Society of Cardiology (ESC) syncope guidelines provide for the first time an algorithm to stratify these patients in the emergency department (ED) and discharge those at low risk.

"I think this is a major advance of this guideline because it goes beyond the individual management of the patient but has organizational and financial implications because it provides a completely different organizational structure of the hospital," task force chair, Michele Brignole, MD, from Ospedali Del Tigullio, Lavagna, Italy, told | Medscape Cardiology.

He observed that, "Seventy-five percent of the cost of syncope is hospitalization; so if you cut hospitalization, you cut 75% of the cost."

Following an initial syncope examination in the ED, including medical history, physical exam with resting and supine blood pressure, and electrocardiography, for all patients, the guidelines recommend that:

  • Patients with low-risk features only, likely to have reflex, situational, or orthostatic syncope, be discharged directly from the ED;

  • Patients with high-risk features should not be discharged but receive an intensive diagnostic evaluation in a syncope unit or ED observation unit, or hospitalized; and

  • Patients with neither high- nor low-risk features should be observed in the ED or in a syncope unit instead of being hospitalized.

The document includes several tables listing high-risk features, such as severe structural or coronary artery disease, syncope during exertion or when supine, and sudden-onset palpitation immediately followed by syncope. It also has criteria for patients with high-risk features favoring initial management in an ED observational unit and/or fast-tracking to a syncope unit vs hospital admission.

Syncope units are available in several US hospitals and in most hospitals in Italy, but some countries have none, said Brignole, who kicked off the session launching the new guidelines here at the European Heart Rhythm Association 2018 meeting. The document was also published online in the European Heart Journal.

Notably, about 1% of patients with syncope die within a month of their ED visit, while about 10% will experience a serious outcome, two thirds of which occur while they are in the ED, task force member Matthew J Reed, MD, an emergency medicine consultant at Edinburgh University, United Kingdom, said during the session.

He noted that several syncope risk-stratification scores are available but perform no better than clinical judgment at predicting short-term serious outcomes. While these scores may be considered, the task force recommends they not be used alone to stratify risk in the ED.

Reed suggested that the new risk algorithm and care pathway, however, should allow more patients to be managed in ED observation and/or syncope units and will limit hospital admission to those "who truly need it."

"These pathways have been shown in several studies that we might be able to reduce admission rates by up to a third if used," he said.

Other Key Messages

The 2018 ESC syncope guidelines update the 2009 version and are the most multidisciplinary available, albeit with cardiologists comprising a minority of the task force, Brignole told the packed lecture hall.

The document includes 113 recommendations (46 of which are class I) and 19 simple rules to guide the diagnosis and management of patients with syncope. It also has a new addendum with practical instructions for physicians on how to perform diagnostic tests and interpret the results.

A key new section recommends video recordings of spontaneous transient loss of consciousness events suspected to be of nonsyncopal nature. Specifically, physicians should consider adding video recording to tilt-table testing to increase the reliability of clinical observation of induced events and encourage patients and their relatives to record spontaneous events or falls, said task force co-chair Angel Moya, MD, Hospital Universitario Vall d'Hebron, Barcelona, Spain.

"Nowadays it is very easy, everyone has a smartphone," he said.

Based on input from internal medicine task force members, the guidelines also recommend physicians consider basic cardiovascular autonomic function tests, such as the Valsalva maneuver, deep-breathing test, or ambulatory blood pressure monitoring, in patients suspected of having neurogenic orthostatic hypotension (OH).

"To all patients with reflex syncope and OH, explain the diagnosis, reassure, explain the risk of recurrence, and give advice on how to avoid triggers and situations. These measures are the cornerstone of treatment and have a high impact in reducing the recurrence of syncope," Moya said.

Finally, the guidelines recommend extending the use of implantable loop recorders (ILRs) for diagnosis in patients with unexplained falls, suspected epilepsy, or recurrent episodes of unexplained syncope and a low risk for sudden cardiac death.

Two class I indications for ILRs in the document are in the early evaluation of patients with recurrent syncope of uncertain origin, no high-risk criteria, and a high likelihood of recurrence, as well as in patients with high-risk criteria in whom a comprehensive evaluation failed to identify a cause of syncope or lead to a specific treatment and who have no primary prevention indications for implantable cardioverter defibrillator or pacemaker.

The ESC guideline, described in the document as being "developed with the special contribution" of the EHRA, is also endorsed by the European Academy of Neurology, the European Federation of Autonomic Societies, the European Federation of Internal Medicine, the European Union Geriatric Medicine Society, and the European Society of Emergency Medicine.

Task force member disclosures are listed in the paper.

European Heart Rhythm Association (EHRA) 2018. Presentations 75-79. Presented March 18, 2018.

Eur Heart J. Published March 19, 2018. Full text

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