Cardiac evaluation for structural abnormalities may not be required in patients presenting with syncope and a normal
Kenton L Anderson1, Alexander Limkakeng, Emily Damuth
1Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA. kentonlanderson@gmail.com
Insights
In syncope patients with a normal electrocardiogram (ECG), structural heart abnormalities are rare. Focus on diagnosing arrhythmias and acute coronary syndrome for effective syncope management.
Area of Science:
- Cardiology
- Internal Medicine
- Emergency Medicine
Background:
- Syncope is a common reason for observation unit admission.
- Current syncope workups often include serial ECGs and cardiac structure analysis.
- The diagnostic yield of cardiac structural analysis in syncope with normal ECGs is unclear.
Purpose of the Study:
- To evaluate the utility of cardiac structural analysis in syncope patients admitted to an observation unit.
- Specifically assess the prevalence of structural abnormalities in patients with a normal electrocardiogram (ECG).
Main Methods:
- Retrospective observational chart review of 323 adult syncope patients over 18 months.
- Exclusion of patients with any ECG abnormalities (arrhythmias, blocks, etc.).
- Definition of abnormal cardiac structure included ejection fraction <45%, severe hypertrophy, or severe valvular disease.
Main Results:
- Of 323 syncope patients, 267 had a normal ECG.
- In the normal ECG group, 235 underwent cardiac structure evaluation; none (0%) had structural abnormalities.
- Two patients (11%) with normal ECGs had abnormal stress echocardiogram results.
Conclusions:
- Structural heart abnormalities are uncommon in syncope patients presenting with a normal ECG.
- Diagnostic efforts should prioritize ruling out arrhythmias and acute coronary syndrome in these patients.
- Cardiac structural analysis may have limited utility when the initial ECG is normal.
Study Objective:
Patients with syncope are frequently managed in observation units and receive serial examinations, monitoring for arrhythmias, and structural analysis of the heart. The primary aim of this study is to determine the utility of structural analysis of the heart in syncope patients who are being managed in an observation unit and have a normal ECG result.
Methods:
This is a retrospective, observational chart review of all consecutive adult patients observed during 18 months at an urban, academic medical center. A case report form with demographics, ECG interpretations, and structural analysis of the heart data was generated and all variables were defined before data extraction. Subjects with an ECG demonstrating any arrhythmia, premature atrial contraction, premature ventricular contraction, pacing, second- and third-degree blocks, and left bundle branch block were excluded from the normal ECG group. An abnormal cardiac structure was defined as an ejection fraction less than 45%, severe hypertrophy, or severe valvular abnormality. Ten percent of cases were evaluated by a second extractor to verify accuracy. Descriptive statistics with confidence intervals (CIs) and interquartile ranges (IQRs; 25%, 75%) are used.
Results:
Three hundred twenty-three subjects were managed in the observation unit for syncope, 48% were men, and their median age was 66 years (25%, 75% IQR 52, 80). Two of 323 (0.6%; 95% CI 0.2% to 2.2%) had an arrhythmia; 1 of 323 had a non-ST-segment myocardial infarction (0.3%; 95% CI 0.1% to 1.7%). Of the 323 patients, 267 had a normal ECG result and 235 (88%) had their cardiac structure evaluated. Forty-eight percent of the normal ECG group were men, and the median age was 65 years (25%, 75% IQR 52, 79). Zero of 235 patients (0%; 95% CI 0% to 1.6%) had a structural abnormality identified on evaluation, and 2 of 18 (11%; 95% CI 3.1% to 32.8%) had an abnormal stress echocardiogram result.
Conclusion:
Structural abnormalities are unlikely in syncope patients with a normal ECG result. Care should focus on excluding arrhythmias and acute coronary syndrome.
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