Diagnostic Yield and Accuracy in a Tertiary Referral Syncope Unit Validating the ESC Guideline on Syncope: a Prospective Cohort Study

Overview

Journal Europace

Publisher Oxford University Press

Specialties Cardiology & Vascular Diseases
Physiology

Date 2020 Nov 21

PMID 33219671

Citations 13

Authors

Jelle S Y de Jong

Minou R Snijders Blok

Roland D Thijs

Mark P M Harms

Martin E W Hemels

Joris R de Groot

Nynke van Dijk

Frederik J de Lange

Affiliations

Soon will be listed here.

Abstract

Aims: To assess in patients with transient loss of consciousness the diagnostic yield, accuracy, and safety of the structured approach as described in the ESC guidelines in a tertiary referral syncope unit.

Methods And Results: Prospective cohort study including 264 consecutive patients (≥18 years) referred with at least one self-reported episode of transient loss of consciousness and presenting to the syncope unit between October 2012 and February 2015. The study consisted of three phases: history taking (Phase 1), autonomic function tests (AFTs) (Phase 2), and after 1.5-year follow-up with assessment by a multidisciplinary committee (Phase 3). Diagnostic yield was assessed after Phases 1 and 2. Empirical diagnostic accuracy was measured for diagnoses according to the ESC guidelines after Phase 3. The diagnostic yield after Phase 1 (history taking) was 94.7% (95% CI: 91.1-97.0%, 250/264 patients) and increased to 97.0% (93.9-98.6%, 256/264 patients) after Phase 2. The overall diagnostic accuracy (as established in Phase 3) of the Phases 1 and 2 diagnoses was 90.6% (95% CI: 86.2-93.8%, 232/256 patients). No life-threatening conditions were missed. Three patients died, two unrelated to the cause of transient loss of consciousness, and one whom remained undiagnosed.

Conclusion: A clinical work-up at a tertiary syncope unit using the ESC guidelines has a high diagnostic yield, accuracy, and safety. History taking (Phase 1) is the most important diagnostic tool. Autonomic function tests never changed the Phase 1 diagnosis but helped to increase the certainty of the Phase 1 diagnosis in many patients and yield additional diagnoses in patients who remained undiagnosed after Phase 1. Diagnoses were inaccurate in 9.4%, but no serious conditions were missed. This is adequate for clinical practice.

Citing Articles

Carotid sinus massage in clinical practice: the Six-Step-Method.

de Lange F, de Jong J, van Zanten S, Hofland W, Tabak R, Cammenga M Europace. 2024; 26(11).

PMID: 39397761 PMC: 11544318. DOI: 10.1093/europace/euae266.

[Diagnostics and treatment of syncope].

Kahler N, Hindricks G, Dagres N, Tscholl V Herz. 2024; 49(5):394-403.

PMID: 39190136 DOI: 10.1007/s00059-024-05260-3.

Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance.

Groppelli A, Rivasi G, Fedorowski A, de Lange F, Russo V, Maggi R Europace. 2024; 26(2).

PMID: 38262617 PMC: 10849184. DOI: 10.1093/europace/euae026.

A cross-sectional nationwide survey of guideline based syncope units in the Netherlands: the SU-19 score-a novel validation for best practices.

van Zanten S, de Jong J, Scheffer M, Kaal E, de Groot J, de Lange F Europace. 2024; 26(1).

PMID: 38190741 PMC: 10793571. DOI: 10.1093/europace/euae002.

Diagnostic and societal impact of implementing the syncope guidelines of the European Society of Cardiology (SYNERGY study).

Ghariq M, van den Hout W, Dekkers O, Bootsma M, de Groot B, Groothuis J BMC Med. 2023; 21(1):365.

PMID: 37743496 PMC: 10518933. DOI: 10.1186/s12916-023-03056-6.

References

Wieling W, van Dijk N, de Lange F, Olde Nordkamp L, Thijs R, Van Dijk J . History taking as a diagnostic test in patients with syncope: developing expertise in syncope. Eur Heart J. 2014; 36(5):277-80. DOI: 10.1093/eurheartj/ehu478. View

Brignole M, Moya A, de Lange F, Deharo J, Elliott P, Fanciulli A . Practical Instructions for the 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018; 39(21):e43-e80. DOI: 10.1093/eurheartj/ehy071. View

Wieling W, Thijs R, Linzer M, de Lange F, Ross A, van Dijk J . Great expectations: what patients with unexplained syncope desire. J Intern Med. 2015; 279(3):259-64. DOI: 10.1111/joim.12450. View

Barnett M, Boddupalli D, Nundy S, Bates D . Comparative Accuracy of Diagnosis by Collective Intelligence of Multiple Physicians vs Individual Physicians. JAMA Netw Open. 2019; 2(3):e190096. PMC: 6484633. DOI: 10.1001/jamanetworkopen.2019.0096. View

Shen W, Sheldon R, Benditt D, Cohen M, Forman D, Goldberger Z . 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017; 14(8):e155-e217. DOI: 10.1016/j.hrthm.2017.03.004. View

Sutton R, van Dijk N, Wieling W . Clinical history in management of suspected syncope: A powerful diagnostic tool. Cardiol J. 2014; 21(6):651-7. DOI: 10.5603/CJ.2014.0097. View

Kenny R, Brignole M, Dan G, Deharo J, Van Dijk J, Doherty C . Syncope Unit: rationale and requirement--the European Heart Rhythm Association position statement endorsed by the Heart Rhythm Society. Europace. 2015; 17(9):1325-40. DOI: 10.1093/europace/euv115. View

Brignole M, Sutton R, Menozzi C, Garcia-Civera R, Moya A, Wieling W . Early application of an implantable loop recorder allows effective specific therapy in patients with recurrent suspected neurally mediated syncope. Eur Heart J. 2006; 27(9):1085-92. DOI: 10.1093/eurheartj/ehi842. View

Wieling W, Thijs R, van Dijk N, Wilde A, Benditt D, Van Dijk J . Symptoms and signs of syncope: a review of the link between physiology and clinical clues. Brain. 2009; 132(Pt 10):2630-42. DOI: 10.1093/brain/awp179. View

10.

Brignole M, Moya A, de Lange F, Deharo J, Elliott P, Fanciulli A . 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018; 39(21):1883-1948. DOI: 10.1093/eurheartj/ehy037. View

11.

Sutton R, Fedorowski A, Benditt D . Letter by Sutton et al Regarding Article, "Abolish the Tilt Table Test for the Workup of Syncope!". Circulation. 2020; 141(25):e944-e945. DOI: 10.1161/CIRCULATIONAHA.120.046864. View

12.

Saal D, Overdijk M, Thijs R, van Vliet I, Van Dijk J . Long-term follow-up of psychogenic pseudosyncope. Neurology. 2016; 87(21):2214-2219. PMC: 5123560. DOI: 10.1212/WNL.0000000000003361. View

13.

Raj V, Rowe A, Fleisch S, Paranjape S, Arain A, Nicolson S . Psychogenic pseudosyncope: diagnosis and management. Auton Neurosci. 2014; 184:66-72. DOI: 10.1016/j.autneu.2014.05.003. View

14.

Brignole M, Menozzi C, Bartoletti A, Giada F, Lagi A, Ungar A . A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J. 2005; 27(1):76-82. DOI: 10.1093/eurheartj/ehi647. View

15.

Bertens L, Broekhuizen B, Naaktgeboren C, Rutten F, Hoes A, van Mourik Y . Use of expert panels to define the reference standard in diagnostic research: a systematic review of published methods and reporting. PLoS Med. 2013; 10(10):e1001531. PMC: 3797139. DOI: 10.1371/journal.pmed.1001531. View

16.

van Wijnen V, Harms M, Go-Schon I, Westerhof B, Krediet C, Stewart J . Initial orthostatic hypotension in teenagers and young adults. Clin Auton Res. 2016; 26(6):441-449. PMC: 5104795. DOI: 10.1007/s10286-016-0382-6. View

17.

van Dijk N, Boer K, Colman N, Bakker A, Stam J, van Grieken J . High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment study. J Cardiovasc Electrophysiol. 2007; 19(1):48-55. DOI: 10.1111/j.1540-8167.2007.00984.x. View

18.

Thijs R, Wagenaar W, Middelkoop H, Wieling W, van Dijk J . Transient loss of consciousness through the eyes of a witness. Neurology. 2008; 71(21):1713-8. DOI: 10.1212/01.wnl.0000335165.68893.b0. View

19.

van Dijk N, Quartieri F, Blanc J, Garcia-Civera R, Brignole M, Moya A . Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the Physical Counterpressure Manoeuvres Trial (PC-Trial). J Am Coll Cardiol. 2006; 48(8):1652-7. DOI: 10.1016/j.jacc.2006.06.059. View