Predictors of Clinically Significant Echocardiography Findings in Older Adults with Syncope: A Secondary Analysis

Abstract

Background: Syncope is a common reason for visit to the emergency department (ED) and is associated with significant healthcare resource utilization. Objective: To develop a risk-stratification tool for clinically significant findings on echocardiography among older adults presenting to the ED with syncope or near-syncope. Design: Prospective, observational cohort study from April 2013 to September 2016 Setting: 11 EDs in the United States. Patients: We enrolled adults (≥60 years) who presented to the ED with syncope or near-syncope who underwent transthoracic echocardiography (TTE). Measurements: Primary outcome was a clinically significant finding on TTE. Clinical, electrocardiogram, and laboratory variables were also collected. Multivariable logistic regression analysis was used to identify predictors of significant findings on echocardiography. Results: A total of 3,686 patients were enrolled. Of those, 995 (27%) received echocardiography. Of these, 215 (22%) had a significant finding on echocardiography. Regression analysis identified five predictors of significant findings: 1) history of congestive heart failure, 2) history of coronary artery disease, 3) abnormal electrocardiogram, 4) high-sensitivity troponin-T >14 pg/ml, and 5) N-terminal pro B-type natriuretic peptide >125 pg/ml. These five variables make up the ROMEO (Risk Of Major Echocardiography findings in Older adults with syncope) criteria. The sensitivity of a ROMEO score of zero for excluding significant findings on echocardiography was 99.5% (95%CI: 97.4–99.9%,) with a specificity of 15.4% (95%CI: 13.0–18.1%). Conclusions: If validated, this risk-stratification tool could help clinicians determine which syncope patients are at very low risk of having clinically significant findings on echocardiography. Registration: ClinicalTrials.gov Identifier NCT01802398.

Appropriate use of transthoracic echocardiography in the investigation of general medicine patients presenting with syncope or presyncope

“…To our knowledge, the ROMEO (Risk of Major Echocardiography findings in Older adults with syncope) is the only other cohort study of a risk stratification tool used to identify patients at low risk of a clinically significant finding on TTE 3. In an analysis of 995 patients undergoing TTE, patients with a ROMEO score of 0 had a probability of a clinically significant TTE finding of 0.8% (95% CI 0.02% to 4.5%) 3. However, unlike the CSRS, the ROMEO tool has not been validated and only applies to patients older than 60 years.…”

“…However, an annualised growth rate of 8.8% in TTE utilisation in Australia, from 1780 per 100 000 population in 2002 to 5035 in 2017, has raised concerns about overutilisation 1 2. Routine use of TTE in all patients presenting with syncope or presyncope in the absence of risk stratification can contribute to this overuse 3. A standardised approach to assessing the likelihood of finding clinically relevant cardiac abnormalities on TTE may address these concerns.…”

A Rational Evaluation of the Syncope Patient: Optimizing the Emergency Department Visit

“…Avoiding unnecessary testing in the ED preserves healthcare resources and reduces ED visit times. In a study aimed at predicting significant echocardiographic findings, the ROMEO (Risk of Major Echocardiographic findings in Older syncope patients) criteria were developed [ 59 ]. The investigators enrolled 915 patients older than 60 years who presented with syncope and had an echocardiography performed.…”

ACR Appropriateness Criteria® Syncope

“…There is no relevant literature that examines the use of transthoracic resting echocardiography in this clinical scenario, especially if a patient who has syncope or presyncope in the setting of a normal ECG and low probability of a cardiac cause of symptoms [66,69,72,73].…”