Syncope is a common problem, but an area in which practice likely varies by region and provider, according to Carrie Herzke, MD, SFHM, of Johns Hopkins University in Baltimore.
The variation in practice also suggests opportunities to safely cut costs, Dr. Herzke said in an interview.
Dr. Herzke will review the recent literature and summarize the current guidelines related to the treatment of syncope in her session, “SyncopE – Effective, Efficient and Economic Evaluations,” on Monday, March 25, at HM19.
“At the end of this session I am hopeful attendees will have a better understanding of the current guidelines, as well as which tests are most likely to be high value in the evaluation of syncope,” Dr. Herzke said. But before testing, clinicians should keep in mind that a history and physical examination are key components to evaluating syncope, she noted.
The European Society of Cardiology Guidelines for Syncope, published in 2018, feature several new concepts for evaluating and managing syncope in clinical settings and testing, including tilt testing, a greater role for prolonged ECG monitoring, use of video recording for suspected syncope, consideration of adenosine sensitive syncope, and consideration of neurological causes of syncope.
The ESC guidelines include using algorithms to determine the appropriate therapy for reflex syncope based on age, severity, and clinical forms. The guidelines also address diagnostic tests, monitoring in and out of the hospital, and treatment options including lifestyle changes and education as well as pharmacotherapy.
Dr. Herzke also will review the 2017 ACC/AHA/HRS Guideline for Patients With Syncope, published in 2017 in the journal Circulation. This guideline has an algorithm for initial evaluation of patients with syncope that includes a history, physical, and ECG. If the cause is known, patients should be assessed for risk and treated; syncope of unknown cause requires further evaluation, and the guideline presents recommendations for additional assessment through means including cardiac imaging, stress testing, blood testing, neurological testing, and tilt table testing.
“The selection of a given diagnostic test, after the initial history, physical examination, and baseline ECG, is a clinical decision based on the patient’s clinical presentation, risk stratification, and a clear understanding of diagnostic and prognostic value of any further testing,” according to the guideline authors.
The 2017 ACC/AHA/HRS Guideline for Patients With Syncope also provides recommendations for the management of cardiovascular conditions, including arrhythmic and structural conditions.
Dr. Herzke said she thinks that the topic of pulmonary embolism and syncope may prompt the liveliest discussion, and she will include several recent articles on this topic in her literature review.
“There has been some debate about how often PE is present in patients presenting after a syncopal episode,” she said. A recent study published in JAMA Internal Medicine found a prevalence of PE from 0.06% to 0.55% among all adults presenting to an ED with syncope and a prevalence of PE from 0.14% to 0.83%.
SyncopE – Effective, Efficient and Economic Evaluations
Monday 1:10 pm
Maryland BD/4-6