| 1. Anderson TS, Thombley R, Dudley RA, Lin GA. Trends in Hospitalization, Readmission, and Diagnostic Testing of Patients Presenting to the Emergency Department With Syncope. Ann Emerg Med. 72(5):523-532, 2018 11. |
Review/Other-Dx |
15,154,920 ED visits |
To determine whether recent guidelines emphasizing limiting hospitalization and advanced diagnostic testing to high-risk patients have changed patterns of syncope care. |
From 2006 to 2014, we identified 15,154,920 survey-weighted ED visits for syncope. Annual rates of ED visits increased from 643 to 771 per 100,000 adults, whereas hospitalizations declined from 36.3% to 24.7% (-11.6% absolute difference; 95% confidence interval [CI] -13.0% to -10.2%). In multistate adjusted analyses, the proportion of ED visits resulting in hospital admission decreased 11.7% (95% CI -11.9% to -11.6%) between 2009 and 2013, whereas the proportion of ED visits resulting in observation care increased by 7.9% (95% CI 7.8% to 8.0%), with no significant change in 30-day ED revisit rates (absolute difference 0.1%; 95% CI -0.1% to 0.3%). The frequency of advanced cardiac testing increased from 13.8% to 17.0%, and neuroimaging increased from 40.6% to 44.3%, driven by increased testing of patients receiving observation and inpatient care. |
4 |
| 2. Probst MA, Kanzaria HK, Gbedemah M, Richardson LD, Sun BC. National trends in resource utilization associated with ED visits for syncope. American Journal of Emergency Medicine. 33(8):998-1001, 2015 Aug. |
Review/Other-Dx |
3,500 ED visits |
To describe national trends in ED visits, advanced diagnostic imaging and admission rates from 2001-2010 for patients presenting with syncope and to seek to describe the diagnoses of admitted patients from 2005-2010 . |
During the study period, there were over 3,500 actual ED visits (representing 11.9 million visits nationally) related to syncope, representing roughly 1% of all ED visits. Admission rates for syncope patients ranged from 27% to 35% and showed no significant downward trend (p=0.1). Advanced imaging rates increased from about 21% to 45% and showed a significant upward trend (p < 0.001). For admitted patients, the most common hospital discharge diagnosis was the symptomatic diagnosis of “syncope and collapse” (36.4%). |
4 |
| 3. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 70(5):620-663, 2017 08 01. |
Review/Other-Dx |
N/A |
To present guidelines for the evaluation and management of patients with syncope. |
No results stated in the abstract. |
4 |
| 4. Thiruganasambandamoorthy V, Stiell IG, Wells GA, Vaidyanathan A, Mukarram M, Taljaard M. Outcomes in presyncope patients: a prospective cohort study. Annals of Emergency Medicine. 65(3):268-276.e6, 2015 Mar. |
Observational-Dx |
881 patients |
To determine the frequency of emergency department (ED) presyncope visit, management, 30-day outcomes, and emergency physicians' outcome prediction. |
Presyncope constituted 0.5% of ED visits. We enrolled 881 patients: mean age 55.5 years, 55.9% women, and 4.7% hospitalized. Among 780 patients with 30-day follow-up, 40 (5.1%) experienced serious outcomes: death 0.3%, cardiovascular 3.1%, and noncardiac 1.8%. Of the 840 patients discharged home, 740 had follow-up data and 14 patients (1.9%) experienced serious outcomes after ED disposition. The area under the receiver operating characteristic curve for physician prediction probability was 0.58 (95% confidence interval 0.38 to 0.78). The incidence of serious outcomes was similar, whereas physician diagnostic confidence and prediction probability varied among the 4 causal groups. |
3 |
| 5. Bastani A, Su E, Adler DH, et al. Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope. Annals of Emergency Medicine. 2018 Dec 07. |
Observational-Dx |
3,581 patients |
To describe the difference in outcomes between patients presenting with syncope to those near-syncope in a large multicenter cohort of older emergency department (ED) patients |
A total of 3,581 patients (mean age 72.8 years; 51.6% men) were enrolled in the study. There were 1,380 patients (39%) presenting with near-syncope and 2,201 (61%) presenting with syncope. Baseline characteristics revealed a greater incidence of congestive heart failure, coronary artery disease, previous arrhythmia, nonwhite race, and presenting dyspnea in the near-syncope compared with syncope cohort. There were no differences in the primary outcome between the groups (near-syncope 18.7% versus syncope 18.2%). A multivariate logistic regression analysis identified no difference in 30-day serious outcomes for patients with near-syncope (odds ratio 0.94; 95% confidence interval 0.78 to 1.14) compared with syncope. |
3 |
| 6. Grossman SA, Babineau M, Burke L, et al. Do outcomes of near syncope parallel syncope?. American Journal of Emergency Medicine. 30(1):203-6, 2012 Jan. |
Observational-Dx |
244 patients |
To determine the incidence of critical interventions or adverse outcomes associated with near syncope and compare these outcomes with syncope. |
After 1870 patients were screened, 244 met the study definition. Of the 244 patients, follow-upwas achieved in 242 (99%). Emergency department hospitalization or 30-day adverse outcomes occurredin 49 (20%) of 244 compared with 68 (23%) of 293 of patients with syncope (P = .40). The most commonadverse outcomes/critical interventions were hemorrhage (n = 6), bradydysrhythmia (n = 6), alteration inantidysrhythmics (n = 6), and sepsis (n = 10). Of patients with near syncope, 49% were admitted comparedwith 69% with syncope (P = .001). |
3 |
| 7. Albassam OT, Redelmeier RJ, Shadowitz S, Husain AM, Simel D, Etchells EE. Did This Patient Have Cardiac Syncope?: The Rational Clinical Examination Systematic Review. JAMA. 321(24):2448-2457, 2019 06 25. |
Review/Other-Dx |
11 studies |
To perform a systematic review of studies of the accuracy of the clinical examination for identifying patients with cardiac syncope. |
Eleven studies of cardiac syncope (N = 4317) were included. Age at first syncope of at least 35 years was associated with greater likelihood of cardiac syncope (n?=?323; sensitivity, 91% [95% CI, 85%-97%]; specificity, 72% [95% CI, 66%-78%]; LR, 3.3 [95% CI, 2.6-4.1]), while age younger than 35 years was associated with a lower likelihood (LR, 0.13 [95% CI, 0.06-0.25]). A history of atrial fibrillation or flutter (n?=?323; sensitivity, 13% [95% CI, 6%-20%]; specificity, 98% [95% CI, 96%-100%]; LR, 7.3 [95% CI, 2.4-22]), or known severe structural heart disease (n?=?222; range of sensitivity, 35%-51%, range of specificity, 84%-93%; range of LR, 3.3-4.8; 2 studies) were associated with greater likelihood of cardiac syncope. Symptoms prior to syncope that were associated with lower likelihood of cardiac syncope were mood change or prodromal preoccupation with details (n?=?323; sensitivity, 2% [95% CI, 0%-5%]; specificity, 76% [95% CI, 71%-81%]; LR, 0.09 [95% CI, 0.02-0.38]), feeling cold (n?=?412; sensitivity, 2% [95% CI, 0%-5%]; specificity, 89% [95% CI, 85%-93%]; LR, 0.16 [95% CI, 0.06-0.64]), or headache (n?=?323; sensitivity, 3% [95% CI, 0%-7%]; specificity, 80% [95% CI, 75%-85%]; LR, 0.17 [95% CI, 0.06-0.55]). Cyanosis witnessed during the episode was associated with higher likelihood of cardiac syncope (n?=?323; sensitivity, 8% [95% CI, 2%-14%]; specificity, 99% [95% CI, 98%-100%]; LR, 6.2 [95% CI, 1.6-24]). Mood changes after syncope (n?=?323; sensitivity, 3% [95% CI, 0%-7%]; specificity, 83% [95% CI, 78%-88%]; LR, 0.21 [95% CI, 0.06-0.65]) and inability to remember behavior prior to syncope (n?=?323; sensitivity, 5% [95% CI, 0%-9%]; specificity, 82% [95% CI, 77%-87%]; LR, 0.25, [95% CI, 0.09-0.69]) were associated with lower likelihood of cardiac syncope. Two studies prospectively validated the accuracy of the multivariable Evaluation of Guidelines in Syncope Study (EGSYS) score, which is based on 6 clinical variables. An EGSYS score of less than 3 was associated with lower likelihood of cardiac syncope (n?=?456; range of sensitivity, 89%-91%, range of specificity, 69%-73%; range of LR, 0.12-0.17; 2 studies). Cardiac biomarkers show promising diagnostic accuracy for cardiac syncope, but diagnostic thresholds require validation. |
4 |
| 8. Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. European Heart Journal. 39(21):1883-1948, 2018 Jun 01. |
Review/Other-Dx |
N/A |
To discuss the guidelines for the diagnosis and management of syncope. |
No results stated in the abstract. |
4 |
| 9. Runser LA, Gauer RL, Houser A. Syncope: Evaluation and Differential Diagnosis. Am Fam Physician. 95(5):303-312, 2017 Mar 01. |
Review/Other-Dx |
N/A |
To discuss syncope, its evaluation, and differential diagnosis. |
No results stated in the abstract. |
4 |
| 10. Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. New England Journal of Medicine. 347(12):878-85, 2002 Sep 19. |
Review/Other-Dx |
7814 participants |
To evaluate the incidence and prognosis of syncope due to specific causes among participants. |
Of 7814 study participants followed for an average of 17 years, 822 reported syncope. The incidence of a first report of syncope was 6.2 per 1000 person- years. The most frequently identified causes were vasovagal (21.2 percent), cardiac (9.5 percent), and orthostatic (9.4 percent); for 36.6 percent the cause was unknown. The multivariable-adjusted hazard ratios among participants with syncope from any cause, as compared with those who did not have syncope, were 1.31 (95 percent confidence interval, 1.14 to 1.51) for death from any cause, 1.27 (95 percent confidence interval, 0.99 to 1.64) for myocardial infarction or death from coronary heart disease, and 1.06 (95 percent confidence interval, 0.77 to 1.45) for fatal or nonfatal stroke. The corresponding hazard ratios among participants with cardiac syncope were 2.01 (95 percent confidence interval, 1.48 to 2.73), 2.66 (95 percent confidence interval, 1.69 to 4.19), and 2.01 (95 percent confidence interval, 1.06 to 3.80). Participants with syncope of unknown cause and those with neurologic syncope had increased risks of death from any cause, with multivariable-adjusted hazard ratios of 1.32 (95 percent confidence interval, 1.09 to 1.60) and 1.54 (95 percent confidence interval, 1.12 to 2.12), respectively. There was no increased risk of cardiovascular morbidity or mortality associated with vasovagal (including orthostatic and medication-related) syncope. |
4 |
| 11. Iacovino JR.. Mortality outcomes of various causes of syncope. Journal of Insurance Medicine (Seattle). 36(1):4-9, 2004. |
Review/Other-Dx |
N/A |
To discuss the mortality outcomes of various causes of syncope. |
No results stated in the abstract. |
4 |
| 12. Kapoor WN.. Evaluation and outcome of patients with syncope. [Review] [120 refs]. Medicine. 69(3):160-75, 1990 May. |
Review/Other-Dx |
N/A |
To derive insights into the diagnostic evaluation and outcomes of patients with syncope. |
The etiology of syncope was not found in approximately 41% of patients. When a cause of syncope was determined, it was most frequently established on the basis of initial history, physical examination and an electrocardiogram (EKG). Furthermore, many of the other entities (e.g., aortic stenosis, subclavian steal) were suggested by findings on the history and physical examinations that required directed diagnostic testing. Initial EKG was abnormal in 50% of patients but led to a cause of syncope infrequently (less than 7%). Prolonged electrocardiographic monitoring, which has assumed a central role in the evaluation of syncope, led to a specific cause in only 22% of patients. Other tests were less often helpful in assigning a cause of syncope. At 5 years, the mortality of 50.5% in patients with a cardiac cause of syncope was significantly higher than the 30% mortality in patients with a noncardiac cause or 24.1% in patients with an unknown cause. At 5 years, a mortality of 50.5% in patients with a cardiac cause of syncope was noted. There were 54 actual deaths in this group as compared to 10.7 expected deaths based on 1980-86 mortality data from Allegheny County, PA (standardized mortality ratio = 5.02). At 5 years, a 33.1% incidence of sudden death was noted in patients with cardiac cause of syncope, as compared with 4.9% in patients with a noncardiac cause and 8.5% in patients with an unknown cause. Mortality and sudden death remained significant for the first 3 years after which the survival curves were parallel. A cardiac cause of syncope was an independent predictor of sudden death and mortality. Recurrences were common but were not associated with an increased risk of mortality or sudden death. Major vascular events were also more frequent in patients with cardiac causes of syncope. |
4 |
| 13. Koene RJ, Adkisson WO, Benditt DG. Syncope and the risk of sudden cardiac death: Evaluation, management, and prevention. [Review]. Journal of Arrhythmia. 33(6):533-544, 2017 Dec. |
Review/Other-Dx |
N/A |
To discuss the causes of syncope that are associated with increased SCD risk (i.e., sudden arrhythmic cardiac death), and the management of these patients, and to discuss the limitations of our understanding of SCD in relation to syncope, and propose future studies that may ultimately address how to improve outcomes of syncope patients and reduce SCD risk. |
No results stated in the abstract. |
4 |
| 14. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clinical Autonomic Research. 21(2):69-72, 2011 Apr. |
Review/Other-Dx |
N/A |
To come to a consensus on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. |
No results stated in the abstract. |
4 |
| 15. Bent C, Lee PS, Shen PY, Bang H, Bobinski M. Clinical scoring system may improve yield of head CT of non-trauma emergency department patients. EMERG. RADIOL.. 22(5):511-6, 2015 Oct. |
Observational-Dx |
500 patients |
To ascertain the predictors of positive head computed tomography (CT) in non-trauma patients and demonstrate feasibility of a clinical scoring algorithm to improve yield. |
Positive CTs were found in 51 of 500 patients (10.2%). Only two clinical factors were significant. Focal neurologic deficit (adjusted OR 20.7; 95% CI 9.4–45.7) and age >55 (adjusted OR 3.08; CI 1.44–6.56). Area under the receiver operator characteristic (ROC) curve for all 3 algorithms were of 0.73–0.83. In proposed Algorithm C, only patients with focal neurologic deficit (major risk factor) or =2 of the five minor risk factors (altered mental status, nausea/vomiting, known malignancy, coagulopathy, and age) would undergo CT imaging. This may reduce utilization by 34% with only a small decrease in sensitivity (98%). |
1 |
| 16. Giglio P, Bednarczyk EM, Weiss K, Bakshi R. Syncope and head CT scans in the emergency department. Emergency Radiology. 12(1-2):44-6, 2005 Dec. |
Review/Other-Dx |
128 patients |
To examine the use and results of head computerized tomography (CT) scans in patients presenting with syncope to the ED of a community hospital. |
One hundred twenty-eight patients were identified. Forty-four patients had their head CT scans performed. In 1 patient, the CT scan showed evidence of infarction in the posterior circulation. In 19 patients, the head CT scan was normal. Twenty-four patients had abnormal findings unrelated to the ED presentation. |
4 |
| 17. Goyal N, Donnino MW, Vachhani R, Bajwa R, Ahmad T, Otero R. The utility of head computed tomography in the emergency department evaluation of syncope. Internal & Emergency Medicine. 1(2):148-50, 2006. |
Review/Other-Dx |
202 patients |
To determine whether head computed tomography aids in the diagnostic investigation of syncope. |
A total of 202 patients had a HCT performed for syncope. Eighty-five patients met one or more of the exclusion criteria. HCT of the remaining 117 patients were analyzed. None of the 117 patients had a HCT finding that was clinically related to the syncopal event. |
4 |
| 18. Grossman SA, Fischer C, Bar JL, et al. The yield of head CT in syncope: a pilot study. Internal & Emergency Medicine. 2(1):46-9, 2007 Mar. |
Observational-Dx |
293 patients |
To determine the yield of routine head CT in ED patients with syncope and analyse the factors associated with a positive CT. |
Of 293 eligible patients, 113 (39%) underwent head CT and comprise the study cohort. Ninety-five patients (84%) were admitted to the hospital. Five patients, 5% (95% CI=0.8%-8%), had an abnormal head CT: 2 subarachnoid haemorrhage, 2 cerebral haemorrhage and 1 stroke. Post hoc examination of patients with an abnormal head CT revealed focal neurologic findings in 2 and a new headache in 1. The remaining 2 patients had no new neurologic findings but physical findings of trauma (head lacerations with periorbital ecchymoses suggestive of orbital fractures). All patients with positive findings on CT were >65 years of age. Of the 108 remaining patients who had head CT, 45 (32%-51%) had signs or symptoms of neurologic disease including headache, trauma above the clavicles or took coumadin. Limiting head CT to this population would potentially reduce scans by 56% (47%-65%). If age >60 were an additional criteria, scans would be reduced by 24% (16%-32%). Of the patients who did not have head CT, none were found to have new neurologic disease during hospitalisation or 30-day follow-up. |
3 |
| 19. Mitsunaga MM, Yoon HC. Journal Club: Head CT scans in the emergency department for syncope and dizziness. AJR Am J Roentgenol. 204(1):24-8, 2015 Jan. |
Observational-Dx |
253 patients |
To determine the yield of acutely abnormal findings on head CT scans in patients presenting to the emergency department with dizziness, near-syncope, or syncope and to determine the clinical factors that potentially predicted acutely abnormal head CT findings and hospital admission. |
Of the 253 patients who presented with dizziness, 7.1% had head CT scans with acutely abnormal findings, and 18.6% were admitted. Of the 236 patients who presented with syncope or near-syncope, 6.4% had head CT scans with acutely abnormal findings, and 39.8% were admitted. The following three clinical factors were found to be significantly correlated with acutely abnormal head CT findings: a focal neurologic deficit (p = 0.003), age greater than 60 years (p = 0.011), and acute head trauma (p = 0.026). |
3 |
| 20. Mendu ML, McAvay G, Lampert R, Stoehr J, Tinetti ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Archives of Internal Medicine. 169(14):1299-305, 2009 Jul 27. |
Review/Other-Dx |
2106 patients |
To determine the frequency, yield, and costs of tests obtained to evaluate older persons with syncope. |
Electrocardiograms (in 99% of admissions), telemetry (in 95%), cardiac enzyme tests (in 95%), and head computed tomographic (CT) scans (in 63%) were the most frequently obtained tests. Results from cardiac enzymes tests, CT scans, echocardiography, carotid ultrasonography, and electroencephalography all affected diagnosis or management in less than 5%of cases and helped determine the etiology of syncope less than 2% of the time. Postural blood pressure (BP) recording, performed in only 38% of episodes, had the highest yield with respect to affecting diagnosis (18%-26%) or management (25%- 30%) and determining etiology of the syncopal episode (15%-21%). The cost per test affecting diagnosis or management was highest for electroencephalography ($32 973), CT scans ($24 881), and cardiac enzymes test ($22 397) and lowest for postural BP recording ($17- $20). The yields and costs for cardiac tests were better among patients meeting, vs those not meeting, the SFSR. For example, the cost per cardiac enzymes test affecting diagnosis or management was $10 331 in those meeting, vs $111 518 in those not meeting, the SFSR. |
4 |
| 21. Choosing Wisely. American College of Emergency Physicians. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation. Available at: http://www.choosingwisely.org/clinician-lists/acep-avoid-head-ct-for-asymptomatic-adults-with-syncope/. |
Review/Other-Dx |
N/A |
To discuss reasons to avoid CT of the head in asymptomatic adult patients with syncope, insignificant trauma, and a normal neurological evaluation. |
No results stated in the abstract. |
4 |
| 22. D'Ascenzo F, Biondi-Zoccai G, Reed MJ, et al. Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the Emergency Department with syncope: an international meta-analysis. [Review]. International Journal of Cardiology. 167(1):57-62, 2013 Jul 15. |
Meta-analysis |
11 studies |
To establish the incidence and etiology of adverse outcomes as well as the predictors, in patients presenting with syncope to the ED. |
11 studies were included. Pooled analysis showed 42% (CI 95%; 32–52) of patients were admitted tohospital. Risk of death was 4.4% (CI 95%; 3.1–5.1) and 1.1% (CI 95%; 0.7–1.5) had a cardiovascular etiology.One third of patients were discharged without a diagnosis, while the most frequent diagnosis was ‘situational,orthostatic or vasavagal syncope’ in 29% (CI 95%; 12–47). 10.4% (CI 95%; 7.8–16) was diagnosed with heart disease,the most frequent type being bradyarrhythmia, 4.8% (CI 95%; 2.2–6.4) and tachyarrhythmia 2.6% (CI 95%;1.1–3.1). Palpitations preceding syncope, exertional syncope, a history consistent of heart failure or ischemicheart disease, and evidence of bleeding were the most powerful predictors of an adverse outcome. |
Good |
| 23. Greve Y, Geier F, Popp S, et al. The prevalence and prognostic significance of near syncope and syncope: a prospective study of 395 cases in an emergency department (the SPEED study). Deutsches Arzteblatt International. 111(12):197-204, 2014 Mar 21. |
Observational-Dx |
395 patients |
To analyse the frequency and causes of near syncope in a German emergency department and the significance of these for prognosis. |
From 17 July to 31 October 2011, 395 patients were seen in the emergency department for a chief complaint of syncope or near-syncope (3% of all emergency patients). Their median age was 70 years, and 55% were men. 62% had experienced syncope, and 38% near-syncope. The patients with near-syncope were younger than those with syncope ( 63 vs. 72 years, p < 0.014) and were also more commonly male (63% vs. 49%, p = 0.006). The two patient groups did not differ significantly with respect to their measured laboratory values and vital parameters or their accompanying medical conditions. Hospitalizations were more common for syncope than for near-syncope (86% vs. 70%, p < 0.001). Etiologies were similarly distributed in the two patient groups, with the main ones being reflex syncope, orthostatic syncope, cardiac syncope, and syncope of uncertain origin. In all, 123 of 379 patients (32%) had further undesired events within 30 days of the event. Multivariable logistic regression revealed that age, heart rate, and renal dysfunction were independent predictors of undesired events, while the type of syncope was not. |
3 |
| 24. Morgan DJ, Dhruva SS, Wright SM, Korenstein D. 2016 Update on Medical Overuse: A Systematic Review. [Review]. JAMA Internal Medicine. 176(11):1687-1692, 2016 11 01. |
Review/Other-Dx |
1445 articles |
To identify and highlight original research articles published in 2015 that are most likely to reduce overuse, organized into three categories: overuse of testing, overtreatment, and services to question. These manuscripts were reviewed and interpreted for their importance to clinical medicine. |
We reviewed 1445 articles, of which 821 addressed overuse. Of these, 112 were deemed most relevant based on originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by author consensus using the same criteria. Findings included doubling of specialty referrals and advanced imaging for simple headache (from 6.7% in 2000 to 13.9% in 2010), unnecessary hospital admission for low-risk syncope often leading to adverse events, and overly frequent screening colonoscopy for 34% of patients. Overtreatment was common with one in four patients with atrial fibrillation at low risk for thromboembolism receiving anticoagulation, 94% of testosterone replacement being off guideline recommendations, 91% of patients restarting opioids after overdose, and 61% of diabetics being treated to potentially harmfully low HbA1C levels (<7%). New findings suggested that testing for C. difficile with molecular assays, cyclobenzaprine and oxycodone/acetaminophen for acute low back pain, and serial follow-up of benign thyroid nodules should be questioned. |
4 |
| 25. Salmela MB, Mortazavi S, Jagadeesan BD, et al. ACR Appropriateness Criteria® Cerebrovascular Disease. J Am Coll Radiol 2017;14:S34-S61. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for cerebrovascular disease. |
No results stated in abstract. |
4 |
| 26. American College of Radiology. ACR Appropriateness Criteria®: Head Trauma. Available at: https://acsearch.acr.org/docs/69481/Narrative/. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. |
No abstract available. |
4 |
| 27. Luttrull MD, Boulter DJ, Kirsch CFE, et al. ACR Appropriateness Criteria® Acute Mental Status Change, Delirium, and New Onset Psychosis. J Am Coll Radiol 2019;16:S26-S37. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for acute mental status change, delirium, and new onset psychosis. |
No results stated in abstract. |
4 |
| 28. Lee RK, Burns J, Ajam AA, et al. ACR Appropriateness Criteria® Seizures and Epilepsy. J Am Coll Radiol 2020;17:S293-S304. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for seizures and epilepsy. |
No results stated in abstract. |
4 |
| 29. Whitehead MT, Cardenas AM, Corey AS, et al. ACR Appropriateness Criteria® Headache. J Am Coll Radiol 2019;16:S364-S77. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for headache. |
No results stated in the abstract. |
4 |
| 30. Expert Panel on Neurologic Imaging:, Juliano AF, Policeni B, et al. ACR Appropriateness Criteria R Ataxia. J. Am. Coll. Radiol.. 16(5S):S44-S56, 2019 May. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for ataxia. |
No results stated in abstract. |
4 |
| 31. Harvey HB, Watson LC, Subramaniam RM, et al. ACR Appropriateness Criteria® Movement Disorders and Neurodegenerative Diseases. J Am Coll Radiol 2020;17:S175-S87. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for movement disorders and neurodegenerative diseases |
No results stated in abstract. |
4 |
| 32. American College of Radiology. ACR Appropriateness Criteria®: Acute Nonspecific Chest Pain—Low Probability of Coronary Artery Disease. Available at: https://acsearch.acr.org/docs/69401/Narrative/. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. |
No abstract available. |
4 |
| 33. Shah AB, Kirsch J, Bolen MA, et al. ACR Appropriateness Criteria® Chronic Chest Pain-Noncardiac Etiology Unlikely-Low to Intermediate Probability of Coronary Artery Disease. J Am Coll Radiol 2018;15:S283-S90. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for chronic chest pain, noncardiac etiology unlikely, low to intermediate probability of coronary artery disease. |
No results stated in abstract. |
4 |
| 34. Akers SR, Panchal V, Ho VB, et al. ACR Appropriateness Criteria R Chronic Chest Pain-High Probability of Coronary Artery Disease. [Review]. J. Am. Coll. Radiol.. 14(5S):S71-S80, 2017 May. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for chronic chest pain, high probability of coronary artery disease/ |
No results stated in abstract. |
4 |
| 35. Batlle JC, Kirsch J, Bolen MA, et al. ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome. J Am Coll Radiol 2020;17:S55-S69. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for chest pain-possible acute coronary syndrome. |
No results stated in abstract. |
4 |
| 36. White RD, Kirsch J, Bolen MA, et al. ACR Appropriateness Criteria® Suspected New-Onset and Known Nonacute Heart Failure. J Am Coll Radiol 2018;15:S418-S31. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for suspected new-onset and known nonacute heart failure. |
No results stated in abstract. |
4 |
| 37. American College of Radiology. ACR Appropriateness Criteria®: Nonischemic Myocardial Disease with Clinical Manifestations (Ischemic Cardiomyopathy Already Excluded). Available at: https://acsearch.acr.org/docs/3082580/Narrative/ |
Review/Other-Dx |
N/A |
To review the literature and provide guidance on the appropriate use of imaging modalities for Nonischemic Myocardial Disease with clinical manifestations. |
No abstract available. |
4 |
| 38. Expert Panel on Cardiac Imaging:, Vogel-Claussen J, Elshafee ASM, et al. ACR Appropriateness Criteria R Dyspnea-Suspected Cardiac Origin. [Review]. J. Am. Coll. Radiol.. 14(5S):S127-S137, 2017 May. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for dyspnea-suspected cardiac origin. |
No results stated in abstract. |
4 |
| 39. Woodard PK, Ho VB, Akers SR, et al. ACR Appropriateness Criteria® Known or Suspected Congenital Heart Disease in the Adult. J Am Coll Radiol 2017;14:S166-S76. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for known or suspected congenital heart disease. |
No results stated in abstract. |
4 |
| 40. American College of Radiology. ACR Appropriateness Criteria®: Acute Chest Pain — Suspected Aortic Dissection. Available at: https://acsearch.acr.org/docs/69402/Narrative/. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. |
No abstract available. |
4 |
| 41. American College of Radiology. ACR Appropriateness Criteria®: Suspected Pulmonary Embolism. Available at: https://acsearch.acr.org/docs/69404/Narrative/. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. |
No abstract available. |
4 |
| 42. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/body-cta.pdf. |
Review/Other-Dx |
N/A |
Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. |
No abstract available. |
4 |
| 43. Prandoni P, Lensing AW, Prins MH, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. New England Journal of Medicine. 375(16):1524-1531, 2016 10 20. |
Observational-Dx |
560 patients |
To assess the prevalence of pulmonary embolism in a large number of patients who were hospitalized for a first episode of syncope, regardless of wheither there were potential alternative explanations of the syncope. |
A diagnosis of pulmonary embolism was ruled out in 330 of the 560 patients (58.9%) on the basis of the combination of a low pretest clinical probability of pulmonary embolism and negative d-dimer assay. Among the remaining 230 patients, pulmonary embolism was identified in 97 (42.2%). In the entire cohort, the prevalence of pulmonary embolism was 17.3% (95% confidence interval, 14.2 to 20.5). Evidence of an embolus in a main pulmonary or lobar artery or evidence of perfusion defects larger than 25% of the total area of both lungs was found in 61 patients. Pulmonary embolism was identified in 45 of the 355 patients (12.7%) who had an alternative explanation for syncope and in 52 of the 205 patients (25.4%) who did not. |
3 |
| 44. Badertscher P, du Fay de Lavallaz J, Hammerer-Lercher A, et al. Prevalence of Pulmonary Embolism in Patients With Syncope. J Am Coll Cardiol. 74(6):744-754, 2019 Aug 13. |
Observational-Dx |
1895 patients |
To determine the prevalence of pulmonary embolism (PE) in patients with syncope. |
Long-term follow-up was complete in 1,380 patients (99%) at 360 days and 1,156 patients (83%) at 720 days. Among 1,397 patients presenting with syncope to the ED, PE was detected at presentation in 19 patients (1.4%; 95% confidence interval [CI]: 0.87% to 2.11%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.5% to 1.5%). In the subgroup of patients hospitalized (47%), PE was detected at presentation in 15 patients (2.3%; 95% CI: 1.4% to 3.7%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.4% to 2.0%). |
2 |
| 45. Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med 2018;54:27-33. |
Review/Other-Dx |
458 patients |
To elucidate the prevalance of both syncope and pre-syncope in pulmonary emoblism (PE) patients to evaluate in these subjects the short-term (30-day) mortality for all-causes according to their hemodynamic status at admission. |
Among the 1716 patients with confirmed acute PE, syncope or pre-syncope was the initial manifestation of the disease in 458 (26.6%) patients. Short-term mortality (30-day) for all causes were significantly higher in patients with syncope/presyncope (42.5% vs 6.2%, p?<?0.0001) while PE patients with presyncope demonstrated a worst short-term outcome, in terms of mortality for all-causes, when compared to those subjects with syncope at admission (47.2% vs 37.4%, p?=?0.03). A statistically significant difference in survival between pre-syncope and syncope was observed only in hemodynamically unstable patients [log rank p?=?0.036]. Cox regression analysis confirmed that pre-syncope resulted an independent predictor of 30-day mortality in hemodynamically unstable patients at admission (HR 2.13, 95% CI 1.08-4.22, p?=?0.029), independently from right ventricular dysfunction (RVD) (HR 6.23, 95% CI 3.05-12.71, p?<?0.0001), age (HR 1.03, 95% CI 1.00-1.06, p?=?0.023) and thrombolysis (HR 2.27, 95% CI 1.11-4.66, p?=?0.025). |
4 |
| 46. Nallamothu BK, Mehta RH, Saint S, et al. Syncope in acute aortic dissection: diagnostic, prognostic, and clinical implications. American Journal of Medicine. 113(6):468-71, 2002 Oct 15. |
Observational-Dx |
728 patients |
To test whether patients with acute aortic dissections who present with syncope are more likely to have suffered dangerous complications (including cardiac tamponade and stroke) and are at an increased risk of in-hospital mortality. |
Syncope was reported in 96 (13%) of 728 patients. Patients with syncope were more likely to die in the hospital (34% [n = 33 deaths]) than were those without syncope (23% [144/632], P=0.01). They were also more likely to have cardiac tamponade (28% [n = 27] vs. 8% [n = 49], P =0.001), stroke (18% [n =17] vs. 4% [n = 27], P =0.001), and other neurologic deficits (25% [n=24] vs. 14% [n=88], P=0.005). After multivariate adjustment, clinical factors independently associated with the occurrence of syncope included a proximal dissection (odds ratio [OR] = 5.5; 95% confidence interval [CI]: 2.5 to 12; P=0.001), cardiac tamponade (OR=3.1; 95% CI: 1.7 to 5.4; P =0.001), and stroke (OR = 3.5; 95% CI: 1.7 to 7.2; P = 0.001). There was a significant association between in-hospital death and syncope after adjustment for demographic characteristics alone (OR = 2.0; 95% CI: 1.2 to 3.5; P = 0.01), but not after adjustment for dissection type, comorbid conditions, andcomplications. |
3 |
| 47. Spittell PC, Spittell JA Jr, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clinic Proceedings. 68(7):642-51, 1993 Jul. |
Review/Other-Dx |
235 patients. |
To promote continued improvement in prompt recognition of aortic dissection by presenting a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. |
At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. |
4 |
| 48. Altintas S, Dinh T, Marcks NGHM, et al. Presence and extent of cardiac computed tomography angiography defined coronary artery disease in patients presenting with syncope. Netherlands Heart Journal. 25(6):376-387, 2017 Jun. |
Observational-Dx |
142 patients |
To investigate presence and extent of CAD in syncope patients. |
Distribution of CAD presence and extent in cardiac and non-cardiac syncope patients was as follows: 72% versus 48% any CAD; 31% versus 26% mild, 8% versus14% moderate and 33% versus 7% severe CAD. Compared with non-cardiac syncope, patients with cardiac syncope had a significantly higher CAD presence and extent (p = 0.001). Coronary calcium score, segment involvement and stenosis score were also higher in cardiac syncope patients (p-values =0.004). Compared to the chest pain control group, patients with cardiac syncope showed a higher, however, non-significant, prevalence of any CAD (72% versus 63%) and severe CAD (33% versus 19%). |
2 |
| 49. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. [Review] [47 refs]. J Am Coll Cardiol. 35(6):1493-501, 2000 May. |
Review/Other-Dx |
27 patients (22 males and 5 females) |
To characterize the clinical profile and identify clinical markers that would enable the detection during life of anomalous coronary artery origin from the wrong aortic sinus (with course between the aorta and pulmonary trunk) in young competitive athletes. |
We reported 27 sudden deaths in young athletes, identified solely at autopsy and due to either left main coronary artery from the right aortic sinus (n = 23) or right coronary artery from the left sinus (n = 4). Each athlete died either during (n = 25) or immediately after (n = 2) intense exertion on the athletic field. Fifteen athletes (55%) had no clinical cardiovascular manifestations or testing during life. However, in the remaining 12 athletes (45%) aged 16 +/- 7, certain clinical data were available. Premonitory symptoms had occurred in 10, including syncope in four (exertional in three and recurrent in two, 3 to 24 months before death) and chest pain in five (exertional in three, all single episodes, < or =24 months before death). All cardiovascular tests were within normal limits, including 12-lead electrocardiogram (ECG) pattern (in 9/9), stress ECG with maximal exercise (in 6/6) and left ventricular wall motion and cardiac dimensions by two-dimensional echocardiography (in 2/2). |
4 |
| 50. Kramer MR, Drori Y, Lev B. Sudden death in young soldiers. High incidence of syncope prior to death. Chest. 93(2):345-7, 1988 Feb. |
Review/Other-Dx |
N/A |
No abstract available. |
No abstract available. |
4 |
| 51. Bruder O, Wagner A, Jensen CJ, et al. Myocardial scar visualized by cardiovascular magnetic resonance imaging predicts major adverse events in patients with hypertrophic cardiomyopathy. Journal of the American College of Cardiology. 56(11):875-87, 2010 Sep 07. |
Observational-Dx |
243 patients |
To establish the prognostic value of a comprehensive cardiovascular magnetic resonance (CMR) examination in risk stratification of hypertrophic cardiomyopathy (HCM) patients. |
During follow-up 20 of the 220 patients died, and 2 patients survived sudden cardiac death due to adequate implantable cardioverter-defibrillator discharge. Most events (n = 16) occurred for cardiac reasons; the remaining 6 events were related to cancer and accidents. Our data indicate that the presence of scar visualized by CMR yields an odds ratio of 5.47 for all-cause mortality and of 8.01 for cardiac mortality. This might be superior to classic clinical risk factors, because in our dataset the presence of 2 risk factors yields an odds ratio of 3.86 for all-cause and of 2.20 for cardiac mortality, respectively. Multivariable analysis also revealed the presence of late gadolinium enhancement as a good independent predictor of death in HCM patients. |
3 |
| 52. Spirito P, Autore C, Rapezzi C, et al. Syncope and risk of sudden death in hypertrophic cardiomyopathy. Circulation. 119(13):1703-10, 2009 Apr 07. |
Observational-Dx |
1511 patients |
To assess the relationship between syncope and sudden death in patients with hypertrophic cardiomyopathy. |
Unexplained (n=153) or neurally mediated (n=52) syncope occurred in 205 patients (14%). Over a 5.6+/-5.2-year follow-up, 74 patients died suddenly. Relative risk of sudden death was 1.78 (95% confidence interval 0.88 to 3.51, P=0.08) in patients with unexplained syncope and 0.91 (95% confidence interval 0.00 to 3.83, P=1.0) in those with neurally mediated syncope compared with patients without syncope. In multivariable analysis, the temporal proximity of unexplained syncope to initial patient evaluation was independently associated with risk of sudden death (P=0.006). Patients with unexplained syncope within 6 months before the initial evaluation showed a 5-fold increase in risk compared with patients without syncope (adjusted hazard ratio 4.89, 95% confidence interval 2.19 to 10.94), a relationship that was maintained throughout all age groups (<18, 18 to 39, and > or =40 years). Older patients (> or =40 years of age) with remote episodes of syncope (>5 years before initial evaluation) did not show an increased risk of sudden death (adjusted hazard ratio 0.38, 95% confidence interval 0.05 to 2.74). |
4 |
| 53. Adamson P, Melton I, O'Donnell J, MacDonald S, Crozier I. Cardiac sarcoidosis: the Christchurch experience. Intern Med J. 44(1):70-6, 2014 Jan. |
Observational-Dx |
18 patients |
To present an overview of the diagnosis, treatment and outcomes of patients with cardiac sarcoidosis managed in Christchurch Hospital, New Zealand. |
Eighteen patients were identified with cardiac sarcoidosis. All the 12 patients that underwent cardiac magnetic resonance imaging (CMR) had abnormal scans. Angiotensin-converting enzyme (ACE) levels were elevated in 4 of 16 patients and troponin (cTn) was elevated in 5 of 15 patients. Endomyocardial biopsies were diagnostic in two of six patients. The principal causes for presentation related to symptomatic high-grade atrioventricular conduction block and congestive heart failure with six patients in each of these groups. In addition, three patients presented with ventricular tachycardia and the remaining three patients presented with atrial fibrillation, recurrent presyncope without proven heart block and an asymptomatic persistent elevation of cardiac troponin. Seven patients had pre-existing, extra-cardiac sarcoidosis and a concomitant diagnosis was made in a further eight cases. Three patients had isolated cardiac involvement at presentation. Sixteen patients received immunosuppressive therapy. Twelve patients had cardiac devices implanted; five pacemakers, five defibrillators and two resynchronising pacemaker defibrillators. During follow up for 0.1-30.8 years, median 4.8 years, two patients died. |
4 |
| 54. Okada DR, Smith J, Derakhshan A, et al. Ventricular Arrhythmias in Cardiac Sarcoidosis. [Review]. Circulation. 138(12):1253-1264, 2018 09 18. |
Review/Other-Dx |
N/A |
No abstract available. |
No abstract available. |
4 |
| 55. Kearney MT, Cotton JM, Richardson PJ, Shah AM. Viral myocarditis and dilated cardiomyopathy: mechanisms, manifestations, and management. [Review] [63 refs]. Postgraduate Medical Journal. 77(903):4-10, 2001 Jan. |
Review/Other-Dx |
N/A |
To discuss the mechanisms, manifestations, and management of viral myocarditis and dilated cardiomyopathy. |
No results stated in the abstract. |
4 |
| 56. Sagar S, Liu PP, Cooper LT Jr. Myocarditis. [Review]. Lancet. 379(9817):738-47, 2012 Feb 25. |
Review/Other-Dx |
N/A |
To provide a clinical classification and guidelines for the assessment and treatment of suspected myocarditis in medical environments and epidemiological research where biopsy is unfeasible at present. |
No results stated in the abstract. |
4 |
| 57. Uemura A, Morimoto S, Hiramitsu S, Hishida H. Endomyocardial biopsy findings in 50 patients with idiopathic atrioventricular block: presence of myocarditis. Japanese Heart Journal. 42(6):691-700, 2001 Nov. |
Experimental-Dx |
50 patients |
To histologically analyze myocardial legions in patients with AV conduction disturbances to determine the presence of myocarditis. |
The myocyte transverse diameter was 15.4±4.1 µm in the AVB group and 11.7±3.1 µm in the N group (P<0.01). The fibrosis area ratio also was significantly higher in the AVB group than in the N group (10.1±6.7% vs 5.1±2.0%). The mean number of lymphocytes per 400-fold magnified field was significantly greater in the AVB group than in the N group (1.9±1.6 vs 1.3±0.4). In addition, disorganization of the cardiac myocytes was noted in 8 patients in the AVB group (16%), myocyte disarrangement in 39 patients (78%), myocytolysis in 23 patients (46%), and nuclear deformity in 21 patients (42%). Myocarditis was diagnosed in 3 of the 50 patients (6%). |
3 |
| 58. Selvanayagam JB, Hawkins PN, Paul B, Myerson SG, Neubauer S. Evaluation and management of the cardiac amyloidosis. [Review] [84 refs]. Journal of the American College of Cardiology. 50(22):2101-10, 2007 Nov 27. |
Review/Other-Dx |
N/A |
To summarize the current state of evidence for the effective evaluation and management of cardiac amyloidosis. |
No results stated in the abstract. |
4 |
| 59. Brembilla-Perrot B, Suty-Selton C, Beurrier D, et al. Differences in mechanisms and outcomes of syncope in patients with coronary disease or idiopathic left ventricular dysfunction as assessed by electrophysiologic testing. Journal of the American College of Cardiology. 44(3):594-601, 2004 Aug 04. |
Experimental-Tx |
180 patients |
To evaluate the causes of syncope and the significance and differences in left ventricular (LV) dysfunction, coronary disease, and idiopathic dilated cardiomyopathy (DCM). |
Sustained monomorphic ventricular tachycardia (VT) was induced in 44 group I patients (37%) and 13 group II patients (21%); ventricular flutter (>270 beats/min) or ventricular fibrillation (VF) was induced in 24 group I patients (19%) and 9 group II patients (15%); and various other arrhythmias were identified. Syncope remained unexplained in 34 group I patients (30%) and 16 group II patients (27%). Prognosis depended on the heart disease: VT or VF induction was a predictive factor of mortality in coronary disease and identified a group with high cardiac mortality (46%), compared with patients with a negative study, who had a lower mortality (6%; p < 0.001) than in other studies. Cardiac mortality was only correlated with LVEF in DCM. |
1 |
| 60. Klem I, Weinsaft JW, Bahnson TD, et al. Assessment of myocardial scarring improves risk stratification in patients evaluated for cardiac defibrillator implantation. Journal of the American College of Cardiology. 60(5):408-20, 2012 Jul 31. |
Observational-Dx |
137 patients |
To test whether assessment of myocardial scarring by cardiac magnetic resonance imaging (MRI) would improve risk stratification in patients evaluated for implantable cardioverter-defibrillator (ICD) implantation. |
During a median follow-up of 24 months the primary endpoint occurred in 39 patients. Whereas the rate of adverse events steadily increased with decreasing LVEF, a sharp step-up was observed for scar size >5% of left ventricular mass (hazard ratio [HR]: 5.2; 95% confidence interval [CI]: 2.0 to 13.3). On multivariable Cox proportional hazards analysis, including LVEF and electrophysiological-study results, scar size (as a continuous variable or dichotomized at 5%) was an independent predictor of adverse outcome. Among patients with LVEF >30%, those with significant scarring (>5%) had higher risk than those with minimal or no (</=5%) scarring (HR: 6.3; 95% CI: 1.4 to 28.0). Those with LVEF >30% and significant scarring had risk similar to patients with LVEF </=30% (p = 0.56). Among patients with LVEF </=30%, those with significant scarring again had higher risk than those with minimal or no scarring (HR: 3.9; 95% CI: 1.2 to 13.1). Those with LVEF </=30% and minimal scarring had risk similar to patients with LVEF >30% (p = 0.71). |
3 |
| 61. Baugh CW, Sun BC, Syncope Risk Stratification Study Group. Variation in diagnostic testing for older patients with syncope in the emergency department. Am J Emerg Med. 37(5):810-816, 2019 05. |
Observational-Dx |
3,686 patients |
To determine the variation, frequency, yield, and costs of tests obtained to evaluate older persons with syncope. |
While most study rates were similar across sites, some were notably discordant (e.g., carotid ultrasound: mean 9.5%, range 1.1% to 49.3%). The most frequently-obtained diagnostic tests were initial troponin (88.6%), chest x-ray (75.1%), head CT (42.5%) and echocardiogram (35.5%). The yield or proportion of abnormal findings by diagnostic test ranged from 1.9% (electrocardiogram) to 42.0% (coronary angiography). Among the most common tests, echocardiogram had the highest proportion of abnormal results at 22.1%. Echocardiogram was an outlier in total cost at $672,648, and had a cost per abnormal test of $3129. |
2 |
| 62. Wong ML, Chiu D, Shapiro NI, Grossman SA. Utility of Chest Radiography in Emergency Department Patients Presenting with Syncope. West J Emerg Med. 17(6):698-701, 2016 Nov. |
Observational-Dx |
575 subjects |
To study the distribution of normal and abnormal chest radiographs in patients presenting with syncope, stratified by those who did or did not have an adverse event at 30 days. |
There were 575 total subjects, 39.7% were male, and the mean age was 57.2 (SD 24.6). Of the 575 subjects, 403 (70.1%) had CXRs performed, and 116 (20.2%) had an adverse event after their syncope. Of the 116 people who had an adverse event, 15 (12.9%) had a positive CXR, 81 (69.8%) had a normal CXR, and 20 (17.2%) did not have a CXR as part of the initial evaluation. Among the 459 people who did not have an adverse event, 3 (0.7%) had a positive CXR, 304 (66.2%) had a normal CXR, and 152 (33.1%) did not have a CXR performed. Fifteen of the 18 patients (83.4%) with an abnormal CXR had an adverse event. Eighty-one of the 385 patients (21.0%) with a normal CXR had an adverse event. Among those who had a CXR performed, an abnormal CXR was associated with increased odds of adverse event (OR: 18.77 (95% CI= [5.3-66.4])). |
3 |
| 63. AlJaroudi WA, Alraies MC, Wazni O, Cerqueira MD, Jaber WA. Yield and diagnostic value of stress myocardial perfusion imaging in patients without known coronary artery disease presenting with syncope. Circ Cardiovasc Imaging. 6(3):384-91, 2013 May 01. |
Observational-Dx |
700 patients |
To investigate the yield of stress MPI for the evaluation of syncope in patients at risk but without known coronary artery disease. |
For patients with abnormal MPI, left heart catheterization were reviewed if performed. There were 700 patients (mean age, 62±15 years; 55% female) who had undergone stress MPI for syncope; 659 patients (94%) had normal perfusion. Of the 41 patients with abnormal MPI, 18 had left heart catheterization (9 were false positive); there were 23 remaining patients with abnormal MPI (16 having moderate to severe perfusion defect size) but who did not have a left-side angiogram and could have undiagnosed significant coronary artery disease. The diagnostic yield of stress MPI was similarly low among all cardiovascular risk categories. |
3 |
| 64. Scott JW, Schwartz AL, Gates JD, Gerhard-Herman M, Havens JM. Choosing wisely for syncope: low-value carotid ultrasound use. J Am Heart Assoc. 3(4), 2014 Aug 13. |
Review/Other-Dx |
1,360,908 beneficiaries |
To evaluate large-scale national trends in utilization of low-value carotid ultrasound imaging for simple syncope. |
We found that 16.5% of all Medicare beneficiaries with simple syncope underwent carotid imaging and 6.5% of all carotid ultrasounds ordered in 2009 were for this low-value indication. These findings were complemented by a manual chart review of 313 patients at a large academic medical center who underwent carotid ultrasound for simple syncope over a 5-year period. For the 48 (15.4%) of 313 patients with stenosis =50%, carotid ultrasound did not yield a causal diagnosis. Only 2% of the 313 patients imaged experienced a change in medications after a positive study, and <1% of patients underwent a carotid revascularization procedure. |
4 |
| 65. Schnipper JL, Ackerman RH, Krier JB, Honour M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope. Mayo Clinic Proceedings. 80(4):480-8, 2005 Apr. |
Observational-Dx |
140 patients |
To determine the diagnostic utility of neurovascular ultrasonography (transcranial Doppler and carotid ultrasonography) in patients with syncope. |
A total of 140 patients participated in the study. The median age of the study patients was 74 years (interquartile range, 66-80 years), and 49% were male. Severe extracranial or intracranial cerebrovascular disease was found on neurovascular ultrasonography in 20 patients (14%; 95% confidence interval [CI], 9.5%-21%). Focal neurologic signs or symptoms or carotid bruits were found in 19 (95%) of 20 patients with positive test results compared with 46 (38%) of 120 patients without severe disease (P<.001). Ultrasonography identified cerebrovascular lesions that may have contributed to the syncopal process in only 2 (1.4%) of 140 patients (95% CI, 0.39%-5.1%), but the lesions were unlikely to have been the primary cause of syncope in either patient. |
3 |
| 66. Kadian-Dodov D, Papolos A, Olin JW. Diagnostic utility of carotid artery duplex ultrasonography in the evaluation of syncope: a good test ordered for the wrong reason. Eur Heart J Cardiovasc Imaging. 16(6):621-5, 2015 Jun. |
Observational-Dx |
495 patients |
To determine diagnostic utility of carotid artery duplex (CUS) in the evaluation of syncope and the identification of new or severe atherosclerosis with the potential to change patient management. |
We reviewed records of 569 patients with CUS ordered for the primary indication of syncope through an accredited vascular laboratory at an academic, urban medical centre. Findings on CUS, patient demographic, clinical and laboratory information, and medications within 6 months of the CUS exam were reviewed. Bivariate relationships between key medical history characteristics and atherosclerosis status (known vs. new disease) were examined. Among 495 patients with complete information, cerebrovascular findings could potentially explain syncope in 2% (10 patients). Optimization of cardiovascular risk factors would benefit patients with known (56.6%) and new atherosclerosis (33.5%) with suboptimal lipid control, (LDL . 70 in 42.2 and 34.9% respectively; LDL . 100 in 15.7 and 20.4%), and those not on high-intensity statin therapy (80 and 87.5%) or antiplatelet medications (13.2 and 50.6%). |
3 |
| 67. Sarasin FP, Junod AF, Carballo D, Slama S, Unger PF, Louis-Simonet M. Role of echocardiography in the evaluation of syncope: a prospective study. Heart. 88(4):363-7, 2002 Oct. |
Observational-Dx |
650 patients |
To study the role of echocardiography in the stepwise evaluation of syncope. |
A systolic murmur was identified in 61 of the 650 patients (9%). Severe aortic stenosis was suspected in 20 of these and was confirmed by echocardiography in eight. Follow up excluded further cases of aortic stenosis. In patients with unexplained syncope (n = 155), routine echocardiography showed no abnormalities that established the cause of the syncope. Echocardiography was normal or non-relevant in all patients with a negative cardiac history and a normal ECG (n = 67). In patients with a positive cardiac history or an abnormal ECG (n = 88), echocardiography showed systolic dysfunction (left ventricular ejection fraction < or = 40%) in 24 (27%) and minor non-relevant findings in the remaining 64. Arrhythmias were diagnosed in 12 of the 24 patients with systolic dysfunction (50%), and in 12 of the 64 remaining patients (19%) (p < 0.01). |
3 |
| 68. Han SK, Yeom SR, Lee SH, et al. Transthoracic echocardiogram in syncope patients with normal initial evaluation. Am J Emerg Med. 35(2):281-284, 2017 Feb. |
Observational-Dx |
241 patients |
To determine whether patients without abnormalities in the initial evaluation benefit from transthoracic echocardiogram (TTE) and the clinical factors predicting an abnormal TTE. |
Of the 115 patients with at least one risk factor, 97 underwent TTE and 27 (27.8%) had TTE abnormalities. In comparison, of the 126 patients without risk factors, 47 underwent TTE and only 1 (2.1%) had TTE abnormalities. Significantly different factors between patients with normal and abnormal TTE findings were entered in a multiple logistic regression analysis, which yielded age [adjusted odds ratio (aOR), 1.09; 95% CI, 1.02-1.15; p=0.006], an abnormal electrocardiogram (ECG) (aOR, 7.44; 95% CI, 1.77-31.26; p=0.010), and a brain natriuretic peptide (BNP) level of >100pg/mL (aOR, 2.64; 95% CI, 1.21-5.73; p=0.011) as independent predictors of TTE abnormalities. The cutoff value of age predicting an abnormal TTE was 59.0years (area under the curve, 0.777; p<0.001). |
3 |
| 69. Chang NL, Shah P, Bajaj S, Virk H, Bikkina M, Shamoon F. Diagnostic Yield of Echocardiography in Syncope Patients with Normal ECG. Cardiology Research & Practice. 2016:1251637, 2016. |
Observational-Dx |
468 patients |
To assess the role of echocardiography as a diagnostic tool in evaluating syncope patients with normal versus abnormal electrocardiogram. |
Three hundred twelve of the total patients (68.6%) had normal ECG. Two-thirds of those patients had echocardiograms; 11 patients (5.7%) had abnormal echo results. Of the aforementioned patients, three patients had previous documented history of severe aortic stenosis on prior echocardiograms. The remaining eight had abnormal but nondiagnostic echocardiographic findings. Echocardiography was done in 93 of 147 patients with abnormal ECG (63.2%). Echo was abnormal in 27 patients (29%), and the findings were diagnostic in 6.5% patients. |
3 |
| 70. Dawn B, Paliwal VS, Raza ST, Mastali K, Longaker RA, Stoddard MF. Left ventricular outflow tract obstruction provoked during dobutamine stress echocardiography predicts future chest pain, syncope, and near syncope. American Heart Journal. 149(5):908-16, 2005 May. |
Observational-Dx |
362 |
To determine whether the anatomic site of dynamic obstruction provoked during dobutamine stress echocardiography (DSE) is important in the prediction of future clinical events in patients without myocardial ischemia. |
One hundred fifty-four of 237 patients had no provoked LV obstruction (group 1). Fifty-four (22.8%) had provoked LV midcavitary (group 2) obstruction, and 29 (12.2%) had outflow tract (group 3) obstruction. During follow-up, chest pain occurred more frequently in groups 2 (46%, P < .05) and 3 (52%, P = .05) as compared with group 1 (31%). A higher incidence of syncope and/or near syncope was noted in group 3 (21% vs 9% in group 1). LVOT obstruction but not midcavitary obstruction was a significant predictor of future chest pain (relative risk 2.63, P = .0021) and syncope and/or near syncope (relative risk 3.11, P = .036). Kaplan-Meier analysis showed a significantly less event-free survival (P = .025) for the combined end point of chest pain, syncope, and/or near syncope in patients with LVOT obstruction. |
3 |
| 71. Suzuki K, Akashi YJ. Exercise stress echocardiography in hypertrophic cardiomyopathy. Journal of Echocardiography. 15(3):110-117, 2017 09. |
Review/Other-Dx |
N/A |
To make a comprehensive summary of exercise stress echocardiography in hypertrophic cardiomyopathy (HCM). |
No results stated in the abstract. |
4 |
| 72. Madeira CL, Craig MJ, Donohoe A, Stephens JR. Things We Do For No Reason: Echocardiogram in Unselected Patients with Syncope. Journal of Hospital Medicine (Online). 12(12):984-988, 2017 12. |
Review/Other-Dx |
N/A |
To discuss why echocardiogram is unnecessary testing for patients with syncope. |
No results stated in the abstract. |
4 |
| 73. Probst MA, Gibson TA, Weiss RE, et al. Predictors of Clinically Significant Echocardiography Findings in Older Adults with Syncope: A Secondary Analysis. J Hosp Med. 13(12):823-828, 2018 12 01. |
Observational-Dx |
3,686 patients |
To develop a risk-stratification tool for clinically significant findings on echocardiography among older adults presenting to the ED with syncope or nearsyncope. |
A total of 3,686 patients were enrolled. Of these, 995 (27%) received echocardiography, and 215 (22%) had a significant finding on echocardiography. Regression analysis identified five predictors of significant findings: (1) history of congestive heart failure, (2) history of coronary artery disease, (3) abnormal electrocardiogram, (4) high-sensitivity troponin-T >14 pg/mL, and 5) N-terminal pro B-type natriuretic peptide >125 pg/mL. These five variables make up the ROMEO (Risk Of Major Echocardiography findings in Older adults with syncope) criteria. The sensitivity of a ROMEO score of zero for excluding significant findings on echocardiography was 99.5% (95% CI: 97.4%-99.9%) with a specificity of 15.4% (95% CI: 13.0%-18.1%). |
2 |
| 74. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. |
Review/Other-Dx |
N/A |
To provide evidence-based guidelines on exposure of patients to ionizing radiation. |
No abstract available. |
4 |
