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9 pages, 647 KiB

Open AccessArticle

Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis

by Ludovico Furlan, Lucia Trombetta, Giovanni Casazza, Franca Dipaola, Raffaello Furlan, Chiara Marta, Filippo Numeroso, Jordi Pérez-Rodon, James V. Quinn, Matthew J. Reed, Robert S. Sheldon, Win-Kuang Shen, Benjamin C. Sun, Venkatesh Thiruganasambandamoorthy, Andrea Ungar, Giorgio Costantino and Monica Solbiati

Medicina 2021, 57(11), 1235; https://doi.org/10.3390/medicina57111235 - 12 Nov 2021

Cited by 5 | Viewed by 2122

Abstract

Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence [...] Read more.

Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients’ data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7–10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7–10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7–10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7–10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial. Full article

(This article belongs to the Special Issue Syncope in the Emergency Department)

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7 pages, 1173 KiB

Open AccessArticle

The Dilemma of Falls in Older Persons: Never Forget to Investigate the Syncope

by Francesca Perego, Beatrice De Maria, Laura Bagnara, Valeria De Grazia, Mauro Monelli, Matteo Cesari and Laura Adelaide Dalla Vecchia

Medicina 2021, 57(6), 623; https://doi.org/10.3390/medicina57060623 - 15 Jun 2021

Cited by 3 | Viewed by 2381

Abstract

Background and objectives: Falls represent a major cause of morbidity, hospitalizations, and mortality in older persons. The identification of risk conditions for falling is crucial. This study investigated the presence of syncope as a possible cause of falls in older persons admitted [...] Read more.

Background and objectives: Falls represent a major cause of morbidity, hospitalizations, and mortality in older persons. The identification of risk conditions for falling is crucial. This study investigated the presence of syncope as a possible cause of falls in older persons admitted to a Sub-Acute Care Unit (SACU) with a diagnosis of accidental fall after initial management in an emergency department and acute hospitalization. Materials and methods: A retrospective monocentric study of patients aged ≥65 years, consecutively admitted to a SACU with a diagnosis of fall-related trauma. All patients underwent a complete assessment of the index event and clinical status. Patients were categorized into three groups according to the identified cause of falls: (1) transient loss of consciousness (T-LOC), (2) unexplained fall (UF), and (3) definite accidental fall (AF). Results: A total of 100 patients were evaluated. T-LOC was present in 36 patients, UF in 37, and AF in 27. Of the 36 patients with T-LOC, a probable origin was identified in most cases (n = 33, 91%), 19 subjects (53%) had orthostatic hypotension, 9 (25%) a cardiac relevant disturbance, 2 (6%) a reproduced vaso-vagal syncope, 2 (6%) severe anemia, and 1 (3%) severe hypothyroidism. The T-LOC group was older and more clinically complex than the other groups. Conclusion: In older patients who recently experienced a fall event, the prevalence of syncope is relevant. In frail and clinically complex patients with falls, the identification of the underlying cause is pivotal and can be achieved through prolonged monitoring and a comprehensive assessment of the person. Full article

(This article belongs to the Special Issue Syncope in the Emergency Department)

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6 pages, 628 KiB

Open AccessArticle

Establishing a Smartphone Ambulatory ECG Service for Patients Presenting to the Emergency Department with Pre-Syncope and Palpitations

by Matthew J. Reed, Alexandra Muir, Julia Cullen, Ross Murphy, Valery Pollard, Goran Zangana, Sean Krupej, Sylvia Askham, Patricia Holdsworth and Lauren Davies

Medicina 2021, 57(2), 147; https://doi.org/10.3390/medicina57020147 - 6 Feb 2021

Cited by 2 | Viewed by 3136

Abstract

Background and Objectives: The Investigation of Palpitations in the ED (IPED) study showed that a smartphone-based event recorder increased the number of patients in whom an electrocardiogram (ECG) was captured during symptoms over five-fold to more than 55% at 90 days compared to [...] Read more.

Background and Objectives: The Investigation of Palpitations in the ED (IPED) study showed that a smartphone-based event recorder increased the number of patients in whom an electrocardiogram (ECG) was captured during symptoms over five-fold to more than 55% at 90 days compared to standard care and concluded that this safe, non-invasive and easy-to-use device should be considered part of on-going care to all patients presenting acutely with unexplained palpitations or pre-syncope. This study reports the process of establishing a smartphone palpitation and pre-syncope ambulatory care Clinic (SPACC) service. Materials and Methods: A clinical standard operating procedure (SOP) was devised, and funding was secured through a business case for the purchase of 40 AliveCor devices in the first instance. The clinic was launched on 22 July 2019. Results: Between 22 July 2019 and 31 October 2019, 68 patients seen in the emergency departments (EDs) with palpitations or pre-syncope were referred to SPACC. Of those, 30 were male and 38 were female, and the mean age was 45.8 years old (SD 15.1) with a range from 18 years old to 80 years old. A total of 50 (74%) patients underwent full investigation. On the first assessment, seven (10%) patients were deemed to have non-cardiac palpitations and were not fitted with the device. All patients who underwent full investigation achieved symptomatic rhythm correlation most with sinus rhythm, ventricular ectopics, or bigeminy. A symptomatic cardiac dysrhythmia was detected in six (8.8%) patients. Three patients had supraventricular tachycardia (4%), two had atrial fibrillation (3%), and one had atrial flutter (2%). Qualitative feedback from the SPACC team suggested several areas where improvement to the clinic could be made. Conclusion: We believe a smartphone palpitation service based on ambulatory care is simple to implement and is effective at detecting cardiac dysrhythmia in ED palpitation patients. Full article

(This article belongs to the Special Issue Syncope in the Emergency Department)

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Review

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12 pages, 2632 KiB

Open AccessReview

Electrocardiographic Patterns in Patients with Neurally Mediated Syncope

by Călina-Patricia Țentea, Csilla-Andrea Eötvös, Roxana-Daiana Lazar, Giorgia Paștiu, Iulia-Georgiana Zehan, Mihai Gabriel Andrei, Adriana Porca, Mihaela Jelnean, Roxana Mihaela Chiorescu, Larisa-Diana Mocan-Hognogi, Sorin Pop and Dan Blendea

Medicina 2021, 57(8), 808; https://doi.org/10.3390/medicina57080808 - 6 Aug 2021

Cited by 2 | Viewed by 5822

Abstract

The baseline electrocardiogram (ECG) is less informative in neurally mediated syncope (NMS) than in arrhythmic syncope. However, some of the ECG patterns present in NMS can have diagnostic and prognostic value in such patients. Electrocardiographic documentation of a syncopal spell and thus identification [...] Read more.

The baseline electrocardiogram (ECG) is less informative in neurally mediated syncope (NMS) than in arrhythmic syncope. However, some of the ECG patterns present in NMS can have diagnostic and prognostic value in such patients. Electrocardiographic documentation of a syncopal spell and thus identification of the ECG changes can be performed during tilt table test (TTT) or during prolonged ECG monitoring. This work reviews the specific ECG patterns in NMS, which are primarily related to the cardioinhibitory reflex. In addition, there are other ECG findings present in patients with NMS that are being analyzed, such as increased heart rate variability as well as specific QRS voltage patterns. In addition to the diagnostic and prognostic value, these ECG patterns in NMS may help improving the selection of patients for pacemaker implant. Full article

(This article belongs to the Special Issue Syncope in the Emergency Department)

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9 pages, 547 KiB

Open AccessReview

Evaluation of Patients with Syncope in the Emergency Department: How to Adjust Pharmacological Therapy

by Martina Rafanelli, Giuseppe Dario Testa, Giulia Rivasi and Andrea Ungar

Medicina 2021, 57(6), 603; https://doi.org/10.3390/medicina57060603 - 11 Jun 2021

Cited by 3 | Viewed by 3075

Abstract

The rate of syncope in the Emergency Department ranges between 0.9 and 1.7%. Syncope is mostly related to a underlying reflex or orthostatic mechanism. A bradycardic or a hypotensive phenotype, may be identified. The latter is the most common and could be constitutional [...] Read more.

The rate of syncope in the Emergency Department ranges between 0.9 and 1.7%. Syncope is mostly related to a underlying reflex or orthostatic mechanism. A bradycardic or a hypotensive phenotype, may be identified. The latter is the most common and could be constitutional or drug induced. Consequently, obtaining an accurate drug history is an important step of the initial assessment of syncope. As anti-hypertensive medication might be responsible for orthostatic hypotension, managing hypertension in patients with syncope requires finding an ideal balance between hypotensive and cardiovascular risks. The choice of anti-hypertensive molecule as well as the therapeutic regimen and dosage, influences the risk of syncope. Not only could anti-hypertensive drugs have a hypotensive effect but opioids and psychoactive medications may also be involved in the mechanism of syncope. Proper drug management could reduce syncope recurrences and their consequences. Full article

(This article belongs to the Special Issue Syncope in the Emergency Department)

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11 pages, 805 KiB

Open AccessReview

Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework

by Jing Li, Susan S. Smyth, Jessica M. Clouser, Colleen A. McMullen, Vedant Gupta and Mark V. Williams

Medicina 2021, 57(6), 570; https://doi.org/10.3390/medicina57060570 - 3 Jun 2021

Cited by 13 | Viewed by 5490

Abstract

Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, research indicates that current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) [...] Read more.

Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, research indicates that current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guidelines (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders’ inputs. We then co-designed with patients and frontline teams, and developed and tested specific strategies. Results: A total of 114 clinicians completed surveys and 32 clinicians and stakeholders participated in interviews. Results from the surveys and interviews indicated low awareness of syncope guidelines, communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change as major barriers to CPG implementation. Thirty-one patients and their family caregivers participated in interviews and expressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. Identifying change methods to address the clinician barriers and patients and family caregivers expectations informed development of the multilevel, multicomponent implementation strategy, MISSION, which includes patient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and a corresponding mobile app, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Conclusions: Effective multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs. Full article

(This article belongs to the Special Issue Syncope in the Emergency Department)

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11 pages, 854 KiB

Open AccessReview

A Rational Evaluation of the Syncope Patient: Optimizing the Emergency Department Visit

by Tarek Hatoum and Robert S. Sheldon

Medicina 2021, 57(6), 514; https://doi.org/10.3390/medicina57060514 - 21 May 2021

Cited by 4 | Viewed by 3032

Abstract

Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a [...] Read more.

Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a structured approach to the syncope patient in the emergency department, highlighting the evidence supporting the role of clinical judgement and the initial electrocardiogram (ECG) in making the preliminary diagnosis and in safely identifying the patients at low risk of short- and long-term adverse events or admitting the patient if likely to benefit from urgent intervention. Clinical decision tools and additional testing may aid in further stratifying patients and may guide disposition. While hospital admission does not seem to offer additional mortality benefit, the efficient utilization of outpatient testing may provide similar diagnostic yield, preventing unnecessary hospitalizations. Full article

(This article belongs to the Special Issue Syncope in the Emergency Department)

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14 pages, 1765 KiB

Open AccessReview

Machine Learning and Syncope Management in the ED: The Future Is Coming

by Franca Dipaola, Dana Shiffer, Mauro Gatti, Roberto Menè, Monica Solbiati and Raffaello Furlan

Medicina 2021, 57(4), 351; https://doi.org/10.3390/medicina57040351 - 6 Apr 2021

Cited by 9 | Viewed by 3012

Abstract

In recent years, machine learning (ML) has been promisingly applied in many fields of clinical medicine, both for diagnosis and prognosis prediction. Aims of this narrative review were to summarize the basic concepts of ML applied to clinical medicine and explore its main [...] Read more.

In recent years, machine learning (ML) has been promisingly applied in many fields of clinical medicine, both for diagnosis and prognosis prediction. Aims of this narrative review were to summarize the basic concepts of ML applied to clinical medicine and explore its main applications in the emergency department (ED) setting, with a particular focus on syncope management. Through an extensive literature search in PubMed and Embase, we found increasing evidence suggesting that the use of ML algorithms can improve ED triage, diagnosis, and risk stratification of many diseases. However, the lacks of external validation and reliable diagnostic standards currently limit their implementation in clinical practice. Syncope represents a challenging problem for the emergency physician both because its diagnosis is not supported by specific tests and the available prognostic tools proved to be inefficient. ML algorithms have the potential to overcome these limitations and, in the future, they could support the clinician in managing syncope patients more efficiently. However, at present only few studies have addressed this issue, albeit with encouraging results. Full article

(This article belongs to the Special Issue Syncope in the Emergency Department)

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