I am a second year general medicine advanced trainee who has done and published multiple research pieces, including a case-control study on general medicine readmissions in the New Zealand Medical Journal and a case report in the New England Journal of Medicine. I have also done a poster presentation at IMSANZ in 2013.about readmissions.
Utility Of Admissions And Investigations And Outcomes In Patients With Intermediate Risk Syncope
Manaf Aljishi, Hutt Hospital, Wellington
Tom Thomson, Hutt Hospital, Wellington
Rowan Hamill, Hutt Hospital, Wellington
Aims: Guidelines suggest that when assessing syncope patients for admission, their risk of serious underlying cause should be stratified into categories: high (warranting admission), low (not needing admission) and intermediate-risk (admission on a cases-by-cases basis)(1). The aim of the study is to measure the utility and diagnostic yield of hospital admissions and investigations for intermediate-risk patients in HVDHB.
Methods: A retrospective study was conducted on syncope patients admitted to Hutt Hospital from 1 July to 31 December 2016. Risk stratification was done using the 2017 American College of Cardiology Guidelines risk criteria(1). Data collected from intermediate-risk patients include patient profile, admission and discharge diagnosis, syncope investigations and 30-day re-syncope and mortality. Syncope diagnoses were classified as vasovagal, orthostatic, cardiogenic, or undifferentiated.
Results: During the study duration, 230 patients presented with syncope but 128 patients (56%) were discharged. Among the admitted patients (102 patients, 44%), 23.8% were high-risk, 2% low-risk, and 74.3% intermediate-risk.
The most common diagnosis on discharge was undifferentiated syncope (37%), followed by vasovagal syncope (23%). There were five cardiogenic syncopes; four were secondary to newly diagnosed atrial fibrillation, and one was sinus bradycardia. Undifferentiated syncope at admission after initial negative investigations was in 35 (47%) patients, and this dropped to 28 (37%) after the admission.
61% of patients had a postural blood pressure done, while 98.7% had an electrocardiography done on admission. Telemetry was ordered on 80% undifferentiated syncopes but also 65% of differentiated syncopes on admission. There was only one positive telemetry (1.7%) that showed new atrial fibrillation. 31% of patients had troponin test done without any positive result. Head imaging to investigate syncope (not for trauma) was performed on 13% of patients with no positive scan. 30-day adverse outcomes occurred in five patients: four had re-syncope and one died due to known malignancy.
Conclusion: Current admission decision-making and investigations for syncope have low yield and need better prioritization. This study resulted in departmental registrar teaching sessions and writing new local syncope admission guidelines in liaison with cardiology department across the DHB.
1. Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, et al. 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.