© 2003 by European Society of Cardiology
Management of patients with syncope referred urgently to general hospitals
1Department of Cardiology, Ospedale S Chiara Trento, Italy; 2Department of Cardiology, Ospedale del Tigullio Lavagna, Italy; 3Department of Cardiology, Ospedale S Maria Nuova Reggio Emilia, Italy; 4Department of Cardiology, Ospedale Umberto I Mestre, Italy; 5Department of Cardiology, Ospedale Policlinico Universitario Bari, Italy; 6Department of Cardiology, Ospedale S Filippo Rome, Italy; 7Department of Cardiology, Ospedale S Maria della Misericordia Udine, Italy; 8Department of Cardiology, Ospedale Riuniti Bergamo, Italy; 9Medtronic Italia SpA Milan, Italy
Manuscript submitted 30 January 2003. Accepted after revision 26 April 2003.
Correspondence: Michele Brignole, MD FESC, Department of Cardiology and Arrhythmologic Centre, Ospedale del Tigullio, Via don Bobbio, Lavagna 16033, Italy. Tel.: +39-0185-329569; fax: +39-0185-306506; E-mail: mbrignole{at}asl4.liguria.it
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Abstract |
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OBJECTIVE: To evaluate the incidence and the strategy of management of syncope admitted urgently to a general hospital.
BACKGROUND: The management of patients with syncope is not standardized.
METHODS: The study was a prospective observational registry from a sample of 28 general hospitals in Italy and enroled all consecutive patients referred to their emergency rooms from November 5th 2001 to December 7th 2001 who were affected by transient loss of consciousness as the principal symptom.
RESULTS: The incidence of syncope was 0.95% (996 of 105,173 patients attending). Forty-six percent were hospitalized, mostly in the Department of Internal Medicine. The mean in-hospital stay was 8.1±5.9 days. A mean of 3.48 tests was performed per patient. A definite diagnosis was made in 80% of cases, neurally-mediated syncope being the most frequent. The findings of each of the 28 hospitals participating in the survey were separately evaluated. We observed great inter-hospital and inter-department heterogeneity regarding the incidence of emergency admission, in-hospital pathways, most of the examinations performed and the final assigned diagnosis. For example, the execution of carotid sinus massage ranged from 0% in one hospital to 58% in another (median 12.5%); tilt testing ranged from 0 to 50% (median 5.8%); the final diagnosis of neurally-mediated syncope ranged from 10 to 78.6% (median 43.3%).
CONCLUSION: Great inter-hospital and inter-department heterogeneity in the incidence and management of syncope was observed in general hospitals. As a consequence, we were unable to describe a uniform strategy for the management of syncope in everyday practice.
Key Words: Syncope, diagnosis, emergency medicine
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionAppendix AAcknowledgementsReferences |
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Data from some pilot studies in Italy[1,
2,3] and the U.K.[4] have suggested that the management of patients with syncope admitted urgently to a general hospital is not standardized. The methods of diagnosis and treatment vary not only from hospital to hospital but also from one department to another (cardiology, general medicine, neurology, etc.) and the procedures followed are very often substantially different from those of the available guidelines, such as those recently issued by the European Society of Cardiology[5]. In this study, we evaluated the incidence of admissions for syncope and the strategy of syncope management in a large cohort of general hospitals that can be regarded as representative of the Italian situation and we provided an epidemiological picture of the usual practice.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionAppendix AAcknowledgementsReferences |
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The study was a prospective registry that included all the patients attending the emergency service of 28 general hospitals in Italy from November 5 2001 to December 7 2001 because of an episode of transient loss of consciousness that had occurred <48 h before as principal symptom.
All 28 centres are large or medium-sized public general hospitals (median of 500 beds, range 150–1500; median of 155,585 inhabitants per district of referral, range 66,432–432,500). Each has a 24-h emergency department and a cardiology ward with a coronary care unit. Together, they serve a population of 4,951,648 inhabitants, which accounts for 8.7% of the total population of Italy. All centres implant pacemakers; 25 have an electrophysiology laboratory, 23 perform tilt testing, and six have a structured syncope unit. In the year 2001, these hospitals had a median of 41,000 attendances at the emergency room (range 18,000 to 91,000).
Study protocol
Since the aim of the study was to record the usual practice, we tried not to influence normal procedures by laying down protocols and rules. In order to collect data, we instructed the personnel of the emergency service to fill in a questionnaire concerning the history of the patients and to note all the examinations performed from admission until discharge from the hospital or admission to another ward. In each hospital, an investigator collected the questionnaires, followed the subsequent diagnostic flow of the patients and recorded all the investigations performed until discharge. The investigator had no contact with the patients and had no role in clinical decisions. He was, however, responsible for reviewing the patients' files and assigning the reported final diagnosis to one of the categories of the classification of loss of consciousness of the Guidelines on Syncope of the European Society of Cardiology[5]. Whenever discrepancies made assignment doubtful or uncertain, he re-evaluated the case with the physicians who had made the diagnosis.
Statistical analysis
Continuous variables were compared by analysis of variance, and proportions were compared by means of the chi-square test. The findings of each of the 28 hospitals participating in the survey were evaluated separately in order to ascertain whether syncope management was heterogeneous among hospitals. The nil hypothesis we tested was that the different results observed in the 28 hospitals were due to the different clinical features of the patients, namely the 13 variables listed in Table 1. To evaluate heterogeneity, we first carried out univariate (logistic, multinomial or linear, as appropriate) regression, in which these 13 variables were treated as independent variables and each was correlated with each of the 24 dependent variables listed in Table 4. For each independent variable that proved to be correlated, with a P value of 0.2 or less, we then performed multivariate regression. The resulting coefficient of linear correlation was calculated according the following formula:
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Squaring the linear correlation coefficient gives the coefficient of determination written as R2. The coefficient of determination expresses the percentage of the total variance explained by the different clinical features of the patients; the remaining variance was assumed to be due to differences in syncope management among hospitals (SPSS 11.0.1. 2001 Statistical Software).
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Results |
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Of the 105,173 patients attending the emergency departments during the period of the survey, 1022 were screened and 996 were found to be affected by loss of consciousness as the principal symptom (Fig. 1); thus, the incidence of syncope as the cause of hospital attendance was 0.95%. Ninety percent of these attended within 6 h of the episode. Data analysis was performed in 980 patients. Their clinical characteristics are shown in Table 1.
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Overall analysis
Fifty-four percent of the total patient population were evaluated and discharged directly from the emergency department and 46% were hospitalized, mostly in the department of internal medicine (Table 2). The mean in-hospital stay was of 8.1±5.9 days. A total of 3195 tests was performed, with a mean of 3.26 tests per patient. The most frequent specialist consultations were cardiological and neurological. A definite diagnosis was made in 80% of cases, neurally-mediated syncope being the most frequent (45% of cases).
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Great inter-department heterogeneity was found in the prevalence of tests (Table 3). Ten patients (1%) died before discharge; causes of death were: sudden death in one case, cardiac non-sudden death in three cases, pulmonary disease in two cases, cancer in three cases, and undefined in one case.
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Analysis by hospital
The findings of each of the 28 hospitals participating in the survey were evaluated separately so that the distribution of the results could be analysed (Table 4). Although the characteristics of the patients were not completely homogeneous among hospitals, they explained only a maximum of 19% of the total variance for each variable (Table 4). We observed great inter-hospital heterogeneity regarding the incidence of emergency admission, in-hospital pathways, most examinations performed and the final assigned diagnosis. For example, the average hospital performed carotid sinus massage in 12.5% of its patients, but the rate of execution of the test ranged from 0% in one hospital to 58% in another (Fig. 2). The average hospital performed tilt testing in 5.8% of its patients, but the rate of execution of the test ranged from 0% in one hospital to 50% in another (Fig. 3). The average hospital performed some form of prolonged ECG monitoring in 23.6% of its patients, but the rate of execution of the test ranged from 2.7% in one hospital to 90.5% in another (Fig. 4). At least one electrophysiological study was actually performed in only 11 hospitals, although 25 had an electrophysiology laboratory. The average hospital made a final diagnosis of neurally-mediated syncope in 43.3% of its patients, but this diagnosis ranged from 10% in one hospital to 78.6% in another (Fig. 5).
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Discussion |
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To our knowledge, this was the largest multicentre population-based survey performed in patients attending to emergency departments for syncope. The main finding was that great inter-hospital (and inter-department) heterogeneity in the incidence and management of syncope was observed in general hospitals. This heterogeneity was minimally explained by a difference in the clinical characteristics of the population referred to the hospitals participating in the study. Indeed, with only three exceptions, the proportion of explained variability was less than 10% of total variance. Thus, we can assume that the main determinant of this different behaviour lies in the different attitudes of the staff. As a consequence, we were unable to describe a uniform strategy for the management of syncope in everyday practice.
A comparative analysis of another 10 population-based studies (nine single-centre and one multicentre)[1,4,6–13] shows similarly great heterogeneity. For example, the diagnosis of neurally-mediated syncope ranged between 13 and 49% of patients and the diagnosis of cardiac syncope ranged between 6 and 46% of patients; syncope remained unexplained in 13–54% of patients.
There are several possible explanations for this heterogeneity. Firstly, a major issue in the use of diagnostic tests is that the causal relationship between a diagnostic abnormality and syncope in a given patient is often presumptive and test sensitivity cannot be measured, as there is no reference or gold standard for most of these tests; therefore, most of the time decisions have to be made on the basis of the patient's history or abnormal findings during asymptomatic periods. Secondly, uncertainty is further compounded by the fact that there is a great deal of variation in how physicians take a history and perform a physical examination, the types of tests requested and how they are interpreted. Procedures seem to be influenced by the speciality and department to which the patient is referred (Table 3). Thirdly, guidelines are often drawn up by specialists in the same field and are not well known or accepted by those of other specialities.
Current practice differs greatly from that observed in syncope units and from that recommended in the guidelines. For example, in a study of patients referred to three syncope units[14,15], in which a standardized evaluation based on the Guidelines of the Italian ‘Associazione Nazionale Medici Cardiologi Ospedalieri’[16] was undertaken, carotid sinus massage was judged appropriate in 57% of patients, tilt testing in 52%, and electrophysiological study in 17%. These figures are higher than those in the present study (Table 4). Such a huge difference cannot be explained by a difference in patient selection. We believe that these tests are largely underused in patients attending the emergency department. Tilt testing, for instance, was undertaken only in 3% of patients attending the emergency room of a university hospital in France (6) and in 1.9% of patients attending 15 hospitals in the Lazio region of Italy (1); in the same studies, the figures for electrophysiological investigation were 2 and 0.1%, respectively. These figures were higher in a population-based study (13) that used a standardized in-hospital protocol, tilt testing being performed in 15% of patients and electrophysiological study in 3.8% of patients. On the other hand, a wealth of evidence testifies to the very limited utility of performing some tests, such as the basic laboratory tests, computed tomography, magnetic resonance imaging, electroencephalography, etc, which, in unselected populations, have a diagnostic yield of 1% or even less[17]. Indeed, their routine use is discouraged by scientific guidelines[5,16,17]. Despite this, they are still frequently performed and were probably overused in this study as well in all the other population-based studies[1–4,6]. Thus, in conclusion, the present study confirms that current practice is not commensurate with current guidelines.
Limitations
Despite the fact that the total number of patients was the highest reported in these kind of studies, the high numbers of hospitals and the high number of independent and dependent variables generate small numbers of observations. These small numbers may have amplified the percentage variations or, otherwise, have resulted in a lack of power of detecting potentially interesting findings.
Practical implications
This study has shown that the strategies for assessment for syncope varies widely among physicians and among hospitals and clinics. More often than not, the evaluation and treatment of syncope is haphazard and unstratified. The result is a broad and, largely inexplicable, variance from centre to centre in the frequency with which various diagnostic tests are applied, the distribution of apparent attributable causes of syncope arrived at by attending clinicians, and the proportion of syncope patients in which the diagnosis remains unexplained.
Assuming the status quo of the syncope evaluation is left as is, diagnostic and treatment effectiveness is unlikely to improve by a substantial amount. Even implementation of the published syncope management guidelines is likely to be diverse, variable in application, and of uncertain benefit. Guidelines from scientific societies should provide the standard, but guidelines are poorly known and sometimes difficult to be applied in clinical practice and physicians of specialities different from that which made the guideline are reluctant to apply it to their patients. Thus, guidelines alone can hardly change everyday practice. They give the background of knowledge to support a different management of syncope.
Therefore what must be done? According to the Guidelines on Syncope of the European Society of Cardiology[5], the initial evaluation consists of history, physical examination including standing blood pressure measurement and standard electrocardiogram. The initial evaluation per se is able to confirm a diagnosis in 23 to 50% of cases[13,15,17]. Most patients can safely be discharged as being affected by a benign form of neurally-mediated syncope. Conversely, if treatment is decided upon or further evaluation is needed patients should be referred to a cohesive, structured care pathway—either delivered within a single syncope facility or as a more multi-faceted service. In this manner, considerable improvement in diagnostic yield and cost effectiveness (i.e. cost per reliable diagnosis) can be achieved by focussing skills and following well defined up-to-date diagnostic guidelines.
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Appendix A |
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TopAbstractIntroductionMethodResultsDiscussionAppendix AAcknowledgementsReferences |
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Evaluation of Guidelines in Syncope Study (EGSYS)
Endorsed by the Working Group on Pacing of European Society of Cardiology, Area Aritmie of Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Associazione Italiana di Aritmologia e Cardiostimolazione (AIAC), Società Italiana di Cardiologia (SIC). With the organizational support of Medtronic Italy SpA, Milano
Steering committee
- Michele Brignole, MD (Chairman)
- Marcello Disertori, MD (Chairman)
- Carlo Menozzi, MD
- Paolo Rizzon, MD
- Paolo Alboni, MD
- Pietro Delise, MD
- Maria Vittoria Pitzalis, MD
- Antonio Raviele, MD
- Massimo Santini, MD
- Marcello Disertori, MD (Chairman)
Study managers
- Alessandro Scivales, BSc (Chairman)
- Roberta Migliorini, BSc
- Daniela Fabrizi, BSc
- Massimiliano Pepe, BSc
- Roberta Migliorini, BSc
Statistical support
- Tiziana De Santo, BSc
List of participating centres and investigators
Alessandria, SS. Antonio e Biagio hospital: Demarchi PG, Diotallevi P; Bagno a Ripoli, S. Maria Annunziata hospital: Bartoletti A, Rosselli A; Bari, Policlinico university hospital: Anaclerio M, Di Biase L; Bentivoglio, Civile hospital: Di Pasquale G, Sassone B; Bergamo, Ospedali Riuniti: Taddei F, Gavazzi A; Brescia, S. Orsola F.B.F hospital: Marchetti A, Benedini G; Cagliari, San Giovannio Di Dio hospital: Lai O, Manzi R; Casarano, F. Ferrari hospital: Pettinati G, Portone AF; Cento, Civile hospital: Dinelli M, Pacchioni F; Chieti, University hospital: Di Iorio C, Di Gerolamo E; Como, S. Anna hospital: Botto GL, Fasana S; Conegliano Veneto, S. Maria dei Battuti hospital: Cannarozzo PP, Sitta N; Crema, Maggiore hospital: Durin O, Inama G; Faenza, Ospedale per gli Infermi: Cornacchia D, Casanova R; Fucecchio, San Pietro Igneo hospital: Del Rosso A; Imperia, Civile hospital: Mureddu R, Musso G; Lavagna, Ospedali del Tigullio: Puggioni E; Mestre, Umberto I hospital: Rossillo A, Giada F; Milano, Niguarda hospital: Lunati M, Di Camillo T; Modena, Policlinico university hospital: Malavasi V, Modena MG; Novara, Ospedale Maggiore della Carità: Occhetta E, Vassanelli C; Parma, Azienda Ospedaliera: Carboni A, Moschini L; Reggio Emilia, S. Maria Nuova hospital: Tomasi C, Guiducci V; Roma, Fatebenefratelli hospital: Azzolini P, Puglisi A; Roma, S. Filippo Neri hospital: Ammirati F, Colivicchi F; Seriate, Bolognini hospital: Giani P, Locatelli A; Trento, S. Chiara hospital: Del Greco M, Cozzio S; Udine, S. Maria della Misericordia hospital: Proclemer A, Baldassi M.
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We wish to thank Silvia Signorelli and Fabiola Zanna for their technical support in preparing the database.
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Footnotes |
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A complete list of investigators appears in Appendix-A 
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References |
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