Diagnostic Yield of Echocardiography in Syncope Patients with Normal ECG

Abstract

Aim. This study aimed to assess the role of echocardiography as a diagnostic tool in evaluating syncope patients with normal versus abnormal electrocardiogram. Methods. We conducted a retrospective study of 468 patients who were admitted with syncope in 2011 at St. Joseph's Regional Medical Center, Paterson, NJ. Hospital records and patient charts, including initial emergency room history and physical, were carefully reviewed. Patients were separated into normal versus abnormal electrocardiogram groups and then further divided as normal versus abnormal echocardiogram groups. Causes of syncope were extrapolated after reviewing all test results and records of consultations. Results. Three hundred twelve of the total patients (68.6%) had normal ECG. Two-thirds of those patients had echocardiograms; 11 patients (5.7%) had abnormal echo results. Of the aforementioned patients, three patients had previous documented history of severe aortic stenosis on prior echocardiograms. The remaining eight had abnormal but nondiagnostic echocardiographic findings. Echocardiography was done in 93 of 147 patients with abnormal ECG (63.2%). Echo was abnormal in 27 patients (29%), and the findings were diagnostic in 6.5% patients. Conclusions. This study demonstrates that echocardiogram was not helpful in establishing a diagnosis of syncope in patients with normal ECG and normal physical examination.

Trends in use of echocardiography in hospitalized patients with syncope

“…Furthermore, as previously mentioned, the absolute number of patients undergoing echocardiography has decreased due to the favorable trends in hospitalization rates. Finally, we did not find a statistically significant reduction in in‐hospital mortality among those receiving an echocardiogram thus supporting the low diagnostic yield of echocardiogram demonstrated in previous studies . While the reasons for its increased utilization in our study need further exploration, it is most likely a result of increased comorbidities and cannot be attributed to inappropriate use.…”

“…Prior research from the late nineties has suggested that routine echocardiogram use in unselected patients with syncope was common and was ordered in two‐thirds of patients presenting with syncope . However, subsequent investigations have demonstrated that echocardiographic abnormalities that impact treatment decisions are uncommon in unselected patients with syncope, particularly in those with a benign cardiac examination, normal ECG, and without pre‐existing cardiac disease . The current ACC/AHA/HRS guidelines recommend against the routine use of cardiac imaging in the evaluation of patients with syncope unless cardiac etiology is suspected on the basis of an initial evaluation, including history, physical examination, or ECG .…”

“…Approximately half of these patients are admitted and undergo further testing at an estimated cost of approximately 2.5 billion dollars per year . In addition to ECG, cardiac rhythm monitoring, and troponin assay, echocardiography is one of the commonly used cardiac tests in these patients, though the yield is known to be relatively low . The current ACC/AHA recommendations for the evaluation and management of patients with syncope therefore advise against the routine use of echocardiography unless cardiac etiology is suspected on the basis of history and physical examination, ECG or other initial testing .…”

Introduction of portable bedside echocardiography to acute general medicine

“…Formal echocardiography is frequently used to stratify risk, particularly in elderly patients with a history of cardiac disease, an abnormal ECG or unexplained recent‐onset syncope . We accept that, when the cardiovascular exam is normal, the positive diagnostic rate of formal echo is low . However many of our patients had abnormal physical signs that were confirmed or ruled out by PBU, thus speeding up the decision‐making process as to whether further investigations were required in or out of hospital .…”

“…5 We accept that, when the cardiovascular exam is normal, the positive diagnostic rate of formal echo is low. 6 However many of our patients had abnormal physical signs that were confirmed or ruled out by PBU, thus speeding up the decision-making process as to whether further investigations were required in or out of hospital. 7 With regard to heart failure, left ventricular function cannot reliably be estimated from physical examination, but both systolic and diastolic dysfunction can be rapidly diagnosed by PBU.…”