The above referenced paper reviews 780 presyncopal patients over age 16 presenting within 24 hours of “a feeling of impending loss of consciousness and (did not lose) consciousness.” Patients were excluded if they had a loss of consciousness, a seizure, or trauma. 4.7% of patients were admitted (41 total patients), and there were 40 “serious outcomes,” with 13 of them happening outside of the hospital. Since those are the ones that keep us up at night, let’s look at those.
1) 76 year old male, bounces back 1 day later and admitted for orthostatic hypotension.
2) 75 year old male, bounces back 3 days later with complete heart block.
3) 84 year old male, bounces back 3 days later in SVT with aberrancy.
4) 74 year old female, bounces back 3 days later, now with dyspnea, diagnosed with PE.
5) 88 year old male, bounces back 4 days later with complete heart block.
6) 55 year old female, bounces back 11 days later with complete heart block.
7) 85 year old male bounces back 11 days later, two days later found to be in complete heart block.
8) 63 year old male bounces back 17 days later, originally with urinary retention, now with AMI.
9) 57 year old female bounces back 18 days later, persistent dizziness and ataxia, worsening, found to have cerebral metastasis.
10) 59 year old female bounces back 20 days later, DOA, history of breast cancer, though not thought to be terminal.
11) 66 year old male bounces back 27 days later, had Afib on stress testing.
12) 49 year old male bounces back 30 days later, several syncopal episodes in past, had VFib at outpatient cardiology follow up.
13) 91 year old nursing home patient with history of dementia and prior stroke, died at SNF, unknown cause, unknown date, but within 30 days.
Of these, I’m not certain orthostatic hypotension should be considered a serious adverse event, nor the stress-test induced Afib. Take out number 13- 91 years old, history of dementia- and that leaves us at a 1.3% adverse outcome rate. Exactly one adverse outcome was under age 55. For comparison, the landmark SF Syncope Criteria paper exclusively looked at those over age 65 and it has a 98% sensitivity.
So what is the take home? To me, there are three. First, is to order – AND DOCUMENT!- telemetry strips on your near syncope (and syncope!) patients. There were a few near misses that were caught because someone actually looked at the cardiac monitor rhythm strips when the sirens were going off. Please, before discharging a patient, if you ordered a cardiac monitor – or if the patient happened to be placed on one – REVIEW AND DOCUMENT IT. This brings me to the second point. It is better to be lucky than good. One of the “serious adverse events” was admitted 11 days after the initial near syncopal event, only to happen to catch an intermittent complete heart block on day 13. The patient was admitted and monitored for two days before his concerning symptoms manifested. The inpatient team had several more hours than the ED to diagnosis this patient and happened to call a consult to Lady Luck for final diagnosis. It’s better to be lucky than good, but sometimes luck favors those well prepared who review the rhythm strips and follows the evidence. Thirdly, if you see enough near syncopal patients, eventually, you’ll get a bounceback in complete heart block. You’ll recall it took the inpatient team two days to find a complete heart block on a patient that bounced back to the ED. To reduce risk, feel free to refer to cardiology, but the reality is that medicine is not a zero risk game. Every time you admit for arrhythmia concerns, this actually means you are certain that there is a higher risk of arrhythmia than the inherent risk of PE or HAI from hospitalization. Let that sink in for a moment, then consider discharging for holter monitor / loop recorder placement instead.
There is risk at every turn no matter the intersection, so choose wisely my friends!