Today’s morning report was part of our quality improvement morning report series. The lecture was based on this article published in the Journal of Hospital Medicine by Madeira and colleagues.
The case they present is a middle-aged woman who presented following a witnessed syncope with no lingering effects. The patient had no cardiac history a normal exam, normal EKG, and normal labs. The question that was posed is “Does my patient need an echo?”
Syncope is responsible for 1% of all ED visits in the US and is independently associated with increased all-cause mortality. The goal of investigating into causes of syncope is to identify modifiable underlying causes with particular attention to cardiac causes of syncope.
The approach to these patients has been made clearer following the publication of the ACC/AHA/HRS guidelines published in 2017 (featuring Dr. Link of the Division of Cardiology @ UTSW).
In patients with syncope, all should receive a history, physical examination, and EKG. The history should be performed carefully with particular attention paid to cardiac risk factors. EKGs are widely recommended due to the availability, ease of performing, low cost, and lack of risks to the patient. EKGs may identify arrhythmogenic substrates, WPW, Brugada syndrome, long QT syndrome, HCM, and arrhythmogenic right ventricular cardiomyopathy. Other than these, however, there are doubts as to the utility of EKG in subsequent management of patients and prognostic use of EKGs.
But after EKGs, how do we know if our patient needs an echocardiogram?
Data suggest that echos are performed in 39-91% of patients presenting with syncope. Most common reasons (and those elicited during morning report) are for evaluation of depressed ejection fractions, aortic stenosis, pulmonary hypertension, and hypertrophic cardiomyopathy. However, these findings in patients without any known cardiac history are only identified in 3% of patients presenting with syncope. It has been estimated that $60,000-132,000 would need to be spent to find one new significant abnormality if all patients without a cardiac history received an echocardiogram in order to identify one significant abnormality.
However, the diagnostic utility of echocardiograms does increase in patients with a cardiac history or abnormal EKG – 27% of patients with known cardiac history or abnormal EKG were found to have an EF<40%.
So how should we approach patients with syncope? All patients should have a careful history and physical exam, with attention paid to findings suggestive of cardiac disease. All patients should have an EKG and orthostatic vital signs. Echocardiograms should only be performed in patients with known cardiac disease or findings suggestive of a cardiac cause of syncope.
J Hosp Med. 2017 Dec;12(12):984-988. doi: 10.12788/jhm.2864. Epub 2017 Oct 18
Heart Rhythm. 2017 Aug;14(8):e155-e217. doi: 10.1016/j.hrthm.2017.03.004. Epub 2017 Mar 9
J Am Coll Cardiol. 2001;37(7): 1921-1928