Things We Do For No Reason: Echocardiogram in Unselected Patients with Syncope

Abstract

Syncope is a common cause of emergency department visits and hospitalizations. Echocardiogram is frequently used as a diagnostic tool in the evaluation of syncope, performed in 39% to 91% of patients. The diagnostic yield of echocardiogram for detecting clinically important abnormalities in patients with a normal history, physical examination, and electrocardiogram (ECG), however, is extremely low. In contrast, echocardiograms performed on patients with syncope with a positive cardiac history, abnormal examination, and/or ECG identify an abnormality in up to 29% of cases, though these abnormalities are not always defi nitively the cause of symptoms. Recently updated clinical guidelines for syncope management from the American College of Cardiology now recommend echocardiogram only if initial history or examination suggests a cardiac etiology, or ECG is abnormal. Universal echocardiography in patients with syncope exposes a signifi cant number of patients to unnecessary testing and cost and does not represent evidence-based or high-value patient care.

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

“…We estimated a minimum sample size of 75 patients would provide 80% power with an alpha error of 0.5% to detect at least a twofold increase in the prevalence of cardiac abnormalities in patients with a CSRS ≥1 compared with a score of 0 or less, assuming a reported prevalence of cardiac abnormalities of no more than 9.5% for all patients with syncope and approximately 20% in patients with high-risk features 13…”

“…TTE is considered appropriate for all patients presenting with syncope/presyncope irrespective of clinical symptoms or signs consistent with a cardiac cause 12. In some US studies, TTE is performed in up to 90% of such patients, despite a very low diagnostic yield of 3% in all patients tested,13 and an even lower yield in low-risk patients 14…”

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].…”

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

“…10 However, routine use of echocardiogram in all syncope patients could result in increased healthcare costs, patient discomfort, and incidental findings of unclear significance, while rarely changing diagnosis or management. 11,12…”

“…10 However, routine use of echocardiogram in all syncope patients could result in increased healthcare costs, patient discomfort, and incidental findings of unclear significance, while rarely changing diagnosis or management. 11,12 In an attempt to reduce potentially unnecessary TTE testing, several studies have tried to identify patients at very low risk of structural heart disease. [13][14][15][16][17] These investigations suggest that TTE is not indicated in syncope patients with a normal ECG and a normal cardiac exam.…”