Syncope Clinical Management in the Emergency Department

Costantino G, Sun BC, Barbic F, et al.
Syncope Clinical Management in the Emergency Department: A Consensus From the First International Workshop on Syncope Risk Stratification in the Emergency Department. Eur Heart J 2015;Aug 4:[Epub ahead of print].

The following are 10 key points to remember from the consensus document on syncope management in the emergency department (ED):

  1. Extensive practice variation, high costs, and questionable benefit associated with some current approaches are undesirable features of syncope evaluation in the ED. Multi-specialty workshop of North American and European syncope experts aimed to write a consensus on the best way to manage syncope patients in the ED.
  2. Syncope is defined as a transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery.
  3. The patient’s assessment should include history, physical examination, electrocardiography (ECG), supine and standing blood pressure measurement, and subsequent tests (such as blood sampling, carotid sinus massage, echocardiogram, chest X-ray, blood gas analysis), according to clinical characteristics and physician judgment.
  4. It is unknown if hospitalization can reduce adverse events in patients with unexplained syncope. The decision to admit a patient should take into account cost, possible adverse events related to hospitalization, and the clinical utility of hospitalization.
  5. Although there is increasing interest in the use of biomarkers for syncope risk stratification, including troponins and brain natriuretic peptides, these biomarkers cannot be recommended for routine care at present.
  6. High-risk patients are those who have at least one high-risk characteristic:
    • Syncope during exertion, in supine position, associated with new onset of chest discomfort, and palpitations before syncope;
    • Family history of sudden death;
    • Heart failure, aortic stenosis, left ventricular outflow tract disease, dilated cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular ejection fraction <35%, previously documented ventricular arrhythmia, coronary artery disease, congenital heart disease, previous myocardial infarction, pulmonary hypertension, previous implantable cardioverter-defibrillator implantation;
    • Hemoglobin <9 g/dl, lowest systolic blood pressure in the ED <90 mm Hg, sinus bradycardia <40 bpm; and
    • New (or previously unknown) left bundle branch block, bifascicular block and first-degree atrioventricular (AV) block, Brugada ECG pattern, ECG changes consistent with acute ischemia, nonsinus rhythm (new), bifascicular block, prolonged QTc (>450 ms).
  7. Low-risk patients are those with one or more low-risk characteristics and without any high-risk characteristics. Low-risk characteristics include:
    • Age <40 years;
    • Syncope occurring while in standing position, standing from supine/sitting position; nausea or vomiting before syncope; feeling of warmth before syncope; syncope triggered by painful or emotionally distressing stimulus or by cough, defecation, micturition; and
    • Prolonged history (years) of syncope with the same characteristics of the current episode.
  8. Patients neither at high, nor at low risk, are patients with any of the following:
    • Comorbidities who would otherwise be at low risk,
    • Without any comorbidity whose syncope has some worrisome characteristics,
    • Without any low- or high-risk characteristics.
  9. Intermediate- and high-risk patients should be monitored in the ED. Low-risk patients do not need additional tests and can be managed as outpatients.
  10. Monitoring should be considered positive in the presence of any the following:
    • Pause (>3 seconds),
    • Sustained or nonsustained ventricular tachycardia whether symptomatic or asymptomatic,
    • High-grade AV block,
    • Bradycardia (<30 bpm) whether symptomatic or asymptomatic,
    • Bradycardia (<50 bpm) in a symptomatic patient, or
    • Tachycardia (>120 bpm) in a symptomatic patient.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Pulmonary Hypertension and Venous Thromboembolism, Implantable Devices, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Pulmonary Hypertension

Keywords: Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Atrioventricular Block, Biological Markers, Blood Pressure, Bradycardia, Cardiomyopathy, Dilated, Cardiomyopathy, Hypertrophic, Carotid Sinus, Death, Sudden, Defibrillators, Implantable, Electrocardiography, Heart Failure, Hypertension, Pulmonary, Myocardial Infarction, Natriuretic Peptide, Brain, Syncope, Tachycardia, Ventricular, Troponin

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