Sex differences in the emergency department evaluation of elderly patients with syncope

Current data suggest that 30%-50% of patients with syncope leave the hospital without a defined etiology of their syncopal event. Recent studies have shown significant differences in both presentation and therapy in women with coronary disease and congestive heart failure.

To assess the impact of sex on the frequency of syncope and the rate of identifying a specific etiology among elderly patients who present to the emergency department (ED), a retrospective chart review was performed during a 1-year period. Consecutive patients older than 65 years presenting with syncope to a large urban teaching hospital were enrolled. Inclusion criterion was documented loss of consciousness with no other obvious etiology of loss of consciousness such as stroke or seizure. Charts were screened for presenting history, ethnicity, sex, comorbid conditions, living circumstances, outpatient medication, and cardiac risk factors and outcomes including acute coronary syndromes, myocardial infarction, and death.

During 1 year of observation, 7496 women (60%) of 12,401 patients over the age of 65 presented to our ED, and 219 (2.9%) of these met inclusion criteria for syncope. In comparison, 4905 (40%) men presented to the ED, 104 (2.1%) of whom had syncope (relative risk of syncope for women vs men, 1.38; 95% confidence interval, 1.09-1.74). Men were more likely to have comorbid conditions including coronary artery disease (p < or = .01), prior myocardial infarction (p < or = .03), and diabetes mellitus (p < or = .03) than were women. No sex differences were noted in living circumstances, such as living alone, with assistance, or in an institution. Forty-two percent of patients received no diagnosis on discharge from the hospital. Sixty-nine of 147 women admitted (47%) had no etiology of their syncope as compared to 27 (32%) of men. The relative risk for no diagnosis in women versus men was 1.67 (95% confidence interval, 1.07-2.61).

Considerable numbers of patients presenting to EDs with syncope remain without a diagnosis. Women, despite being less likely to have concomitant coronary artery disease or diabetes, are significantly more likely to present to an ED with syncope, yet less likely to be discharged with a defined etiology.