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You'll Faint When You See the Bill

The most expensive tests for evaluating syncope usually don't influence diagnosis or management, and the least expensive — and most useful — test is underused.

Hospitalization for syncope is common and frustrating, especially in elders. Loss of consciousness can be caused by a wide range of conditions, many benign but some life-threatening. These investigators undertook a detailed medical records review of all 1920 patients aged 65 admitted to a single U.S. hospital who presented to the emergency department with syncope between 2002 and 2006 (mean age, 79; 8.5% with a prior admission for syncope). The investigators recorded how often various diagnostic tests were performed, calculated the cost of the tests, and determined how frequently the results affected diagnosis or management.

Electrocardiography, cardiac biomarker studies, and telemetry monitoring were each performed in at least 95% of patients during hospitalization. Head computed tomography was performed in 63%, and echocardiography was performed in 39%; electroencephalography (EEG), carotid ultrasound, and cardiac stress testing were performed less frequently. Postural vital signs were recorded in only 38% of patients. Abnormalities — including minor abnormalities — were found most commonly on echocardiograms (63% yielded abnormal findings).

The cause of syncope remained unidentified at discharge in 47% of the patients. No diagnostic test except postural blood pressure measurement helped determine the etiology in >5% of cases in which they were obtained. Postural blood pressure abnormalities (drops in systolic blood pressure of 10 mm Hg or to 90 mm Hg upon sitting or standing) helped identify the etiology in 21% of cases in which the test was used, affected diagnosis in 26%, and affected management in 30%. Postural blood pressure measurement was by far the least expensive test ($17 per test affecting diagnosis or management, vs. $710 for telemetry and $32,973 for EEG). All the tests had higher yields in patients who met the San Francisco Syncope Rule (a prospectively validated score for identifying patients at high risk for serious causes of syncope) than in patients who did not.

Comment: In this single-center study, the evaluation of syncope varied widely and often included tests with minimal diagnostic yield, incurring considerable expense. Although the optimal approach to evaluating syncope remains unknown, these findings suggest that (1) postural blood pressure should be measured in all patients with syncope; (2) more-expensive tests should be used judiciously and, possibly, limited to patients at high risk for serious etiologies; and (3) even after extensive testing, the etiology of syncope in elders often cannot be determined.

— Frederick A. Masoudi, MD, MSPH

Published in Journal Watch Cardiology August 12, 2009

Citation(s):

Mendu ML et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med 2009 Jul 27; 169:1299.

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