Effectiveness and Cost-Efficacy of Syncope Workup in a Dedicated Outpatient Syncope Center

Syncope is a common and costly health problem that involves a large part of the population. Most patients are being evaluated in emergency rooms after having syncope and continue their work up on an ambulatory basis, with multiple tests of relatively low yield. We hereby describe a targeted workup of syncope in a dedicated outpatient syncope center(SC), where 198 patients were evaluated since 2013. ECG findings: 98% normal sinus rhythm, 89% normal QRS complex; 7.5% bundle branch block; 4% LVH pattern; 1.5% Brugada like changes; 6.5% early repolarization pattern; 4.5% PR shorter than 0.12 sec and 3.5% longer than 0.2 sec; 8% QTc longer than 440 msec.

Tests performed during evaluation at SC included: carotid sinus massage (33.5%), holter (15%), orthostatic test (62.5%), echo (17%), tilt-test (75.5%), ergometry (8%), adenosine test (1.5%), ajmalin test (2.5%), EPS (3%), external loop recorder (3%). Implantation of implantable loop recorder (ILR) was advised in 20.5% (and performed in 17.4%). Final diagnosis was reached in 69% that included: 2.5% AVB, 2.5% - carotid sinus syndrome, 9% orthostatic hypotension, 2% - pseudosyncope, 50% - vasovagal syncope, 3% true vertigo. Treatment included life style changes in 76%, medication change in 11.5%, pacemaker implantation in 5%. All patients with ILRs are still carrying them and have not reached diagnosis yet.

Reviewing the appropriateness (by ESC syncope guidelines) of tests that were performed in the community prior to referral to SC unnecessary tests included 51 EEGs (5,495$), 36 head CTs (5,851$), 42 echoes (4,937$), 42 holters (5,828$), 25 ergometries (1,944$), 15 NICEs (1,628$), 7 head MRIs (3,256$), and 4 stress-echoes (1,107$). Total savings from the examination of 198 patients in a specialized Syncope Center in 1.5 years was 30,047$ (approximately 1500$/patient).

Thus the examination of patients in SC has a high diagnostic yield and saves unnecessary tests and costs