Case Scenario

A 78-year-old patient in good health has hypertension that is well controlled with medication. One fall afternoon, the patient was raking leaves when they suddenly passed out. The patient had no dizziness or other symptoms before or after the event. Their partner saw them fall and rushed over; the patient woke up instantly, felt fine, stood up, and started walking. The patient did not hit their head and was taken to the hospital, where a computed tomography (CT) scan of the head, carotid Doppler, and echocardiography were performed before the patient was admitted to a telemetry unit. The patient's blood pressure was elevated at times, and carotid artery studies showed mild stenosis; therefore, the patient was started on atorvastatin (Lipitor), and their lisinopril dose was increased. No specific cause of syncope was found after two days of monitoring. The patient was scheduled for follow-up appointments with a neurologist and cardiologist. The day after discharge from the hospital, the patient passed out again. The patient's blood pressure was 90/60 mm Hg.

Clinical Commentary

BENEFITS AND RISKS OF HOSPITALIZATION

Sometime in their lives, 40% of adults will have syncope, and many of them will go to the hospital for a workup and be admitted.¹ Approximately 1.5% of all emergency department visits are for syncope, and between 27% and 35% of these people are admitted to the hospital. The average length of stay is two days, and the average cost per admission in 2011 was $28,000.² Many people admitted for syncope were previously admitted for the same diagnosis and had the same workup; one study estimated that the rate of recurrent syncope admissions is 25%.² That same study showed that 42% of patients with syncope had no identifiable cause, and the most common causes when found were hypokalemia, atrial fibrillation, ventricular tachycardia, dehydration, and hyponatremia. The mortality rate for patients with primary syncope is 0.2% over one year.²

The 2017 American College of Cardiology/American Heart Association/Heart Rhythm Society syncope guidelines present a data-driven algorithm to initiate a workup for syncope and determine which people are at high risk.³ After a detailed history, physical examination, and electrocardiography, most people can be identified as low risk based on normal findings or as higher risk based on abnormal or worrisome findings.⁴ In the latter category, the guidelines suggest other testing and treatment that may be beneficial as determined by the specific abnormal findings.

An analysis of a large cohort of patients who presented with syncope between 2004 and 2012 found that most people hospitalized were older and had more comorbidities than people evaluated as outpatients, putting them at higher risk of a secondary cause of syncope. Monitoring was the primary reason for admission. People who were hospitalized had a far higher 30-day and one-year mortality rate than those not hospitalized, which was likely related to their underlying diseases. Most causes of death in this cohort were unrelated to syncope.⁵ Hospitalization did not increase the chances of finding a life-threatening arrhythmia or a cause of syncope that was imminently dangerous. People admitted to the hospital were more likely to have nonfatal arrhythmias and nonarrhythmic causes of syncope identified earlier, without any change in mortality.⁶

Although most hospital admissions for syncope do not lead to the identification of an immediately life-threatening cause, hospitalization leads to more adverse events. One study found that 7.4% of people with syncope experienced a serious adverse event within 30 days if they were hospitalized, and 3.2% if not hospitalized.⁷ In a cohort of people at low risk who were admitted for syncope, 15% experienced adverse events in the hospital, including delirium, transfusion errors, falls, hypoglycemia, and medication errors. A total of 32% of people admitted to the hospital had unrelated incidental findings, leading to more testing and specialist referrals. Overall, patients who were admitted had an average of 11 diagnostic tests during their admission.⁸

TESTING IN THE HOSPITAL

The most common tests in people hospitalized for syncope are CT scan of the head, echocardiography, carotid Doppler, and cardiac monitoring. In one study, 76% of patients had a head CT scan, 69.7% had echocardiography, and 33%, had carotid Doppler.⁹ These tests were found to increase the total cost of hospitalization and the length of stay. The total cost of hospitalization for syncope among Medicare recipients is $2.4 billion per year⁹; therefore, the question is whether this testing helps uncover causes of syncope that are life-threatening or cannot be discovered in the outpatient setting.