Uselessness of Echocardiography in Fast Track Evaluation of Patients with Syncope

Syncope workup typically necessitates hospitalization in high risk patients, with significant economic burden, overutilization of hospital resources and yields negative results in up to 30% of cases.

Methods: We established a one-bed syncope unit (SU) at our emergency department for the purpose of fast track evaluation of intermediate risk (IR) syncope patients.

Patients with one of IR criterion (age>65, abnormal ECG, known structural heart disease, exercise syncope, sudden onset, supine position, palpitations prior to syncope, trauma or occupational risk) were admitted to SU. Standard workup in all patients included: holter-monitoring (10 hours at least), echocardiography and orthostatic testing.

Results: Over 4 years 442 patients fulfilled the criteria and were admitted to the SU. Baselines characteristics are shown in table. In addition to the standard work up, patients underwent: carotid sinus massage (81.2%), tilt test (44.5%), ergometry (10.2%), adenosine test (3.1%) and EPS (3.9%). 17 patients were referred to ICM implantation.

Full workup was completed within 24 hours and the diagnosis was established in 94.2% (reflex mediated syncope in 76.71%, orthostatic hypotension in 6.8%; bradyarrhythmia in 9.9%). Interestingly, echocardiography yielded the diagnosis in only one patient who suffered of severe aortic stenosis. This patient had an overt systolic murmur on physical examination.

Conclusion: The use of echocardiography in all patients with syncope and no auscultation finding is probably unjustified and should not be used routinely.

Table 1. Baselines characteristics of patients admitted to syncope unit