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Syncope Evaluation in the Emergency Department Study - SEEDS
Description:
The goal of the study was to evaluate whether a designated syncope unit in the emergency department improves diagnostic yield and reduces hospital admission compared with usual care in patients with syncope of unknown cause.
Study Design
Study Design:
Patients Screened: 3,502
Patients Enrolled: 262
Mean Follow Up: Mean follow-up 18 months
Mean Patient Age: Mean age 64 years
Female: 51
Patient Populations:
Presentation to the emergency department with syncope of unknown cause and an intermediate risk for an adverse cardiovascular event
Exclusions:
Identified cause of syncope, presence of any condition requiring hospitalization, or nonsyncope syndromes
Primary Endpoints:
Diagnostic yield, and hospital admission rate at the completion of the emergency department evaluation
Secondary Endpoints:
Net diagnostic yield and length of hospital stay at the completion of the evaluation of the index event, and all-cause mortality and recurrent syncope during follow-up
Drug/Procedures Used:
Patients presenting to the emergency department at the Mayo Clinic, Rochester, Minnesota, with syncope of unknown cause were categorized as low, intermediate, or high risk for an adverse cardiovascular outcome. Patients categorized as intermediate risk were randomized to the syncope unit evaluation (n=51) or standard care (n=52). Syncope unit evaluation included continuous cardiac monitoring for up to six hours in a designated area staffed by a physician and registered nurse. Monitoring of vital signs and blood pressure were done hourly, and echocardiography was performed in patients with an abnormal ECG or abnormal cardiovascular findings.
Principal Findings:
Baseline data were well matched between the treatment groups. Presentation with an abnormal ECG occurred in 57% of patients, and 56% of patients reported a previous syncope episode. Half of the patients in the trial were hypertensive.
The presumptive diagnosis at discharge from the emergency department was established more frequently in the syncope unit group compared with usual care (67% vs. 10%, p<0.001). Hospital admission was required less frequently in the syncope unit group (43% vs. 98%, p<0.001). Additionally, total number of hospitalization days for the index event was less in the syncope unit group (64 days vs. 140 days), although the mean duration of hospital stay did not differ (2.9 days for syncope unit vs. 2.7 days for usual care, p=0.18).
At two-year follow-up, there was no significant difference in survival (97% for syncope unit vs. 90% for usual care, p=0.30) or survival free from recurrent syncope (88% vs. 89%, p=0.72). No adverse events were reported as a result of the study.
Interpretation:
Among patients presenting to the emergency department with syncope of unknown cause who were classified as intermediate risk, use of a dedicated syncope evaluation unit was associated with more frequent diagnosis in the emergency department and less need for hospital admission and fewer total hospitalization days compared with usual care.
Due to the large number of syndromes that are associated with a syncope episode, the diagnosis of the cause of a syncope episode can be difficult, time consuming, and potentially expensive due to the need for many diagnostic measures. The present trial, while demonstrating promising results, was conducted only at a single-center and was unblinded. Further evaluation is needed to determine if the strategy can be more widely applicable. Additionally, a cost analysis would be needed to determine if the cost for establishing and maintaining a dedicated syncope evaluation unit is offset by the lower total hospitalization days.
References:
Shen WK, Decker WW, Smars PA, et al. Syncope Evaluation in the Emergency Department Study (SEEDS). A Multidisciplinary Approach to Syncope Management. Circulation 2004 Nov 9; [Epub ahead of print].
Presented by Win K. Shen at the American Heart Association Scientific Sessions, November 2004, New Orleans, LA.
Clinical Topics: Noninvasive Imaging, Echocardiography/Ultrasound
Keywords: Follow-Up Studies, Minnesota, Syncope, Blood Pressure, Emergency Service, Hospital, Patient Discharge, Echocardiography, Length of Stay
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