Syncope in the Pediatric Emergency Department
Syncope in the Pediatric Emergency Department
Background: The American Heart Association recommends a "meticulous history" when evaluating patients with an initial episode of syncope. However, little is known about which historical features are most helpful in identifying children with undiagnosed cardiac syncope.
Objectives: Our objectives were 1) to describe the cardiac disease burden in Emergency Department (ED) syncope presentations, and 2) to identify which historical features are associated with a cardiac diagnosis.
Methods: Using syncope presentations in our ED between May 1, 2009 and February 28, 2013, we 1) performed a cross-sectional study describing the burden of cardiac syncope, and 2) determined the sensitivity and specificity of four historical features identifying cardiac syncope.
Results: Of 3445 patients, 44.5% were male presenting at 11.5 ± 4.5 years of age. Of patients with a cardiac diagnosis (68, ~2%), only 3 (0.09%) were noted to have a previously undiagnosed cardiac cause of syncope: 2 with supraventricular tachycardia and 1 with myocarditis. Among the three cases and 100 randomly selected controls, the respective sensitivity and specificity of the historical features were 67% and 100% for syncope with exercise, 100% and 98% for syncope preceded by palpitations, and 67% and 70% for syncope without prodrome. The presence of at least two features yielded a sensitivity of 100% and specificity of 100%.
Conclusions: Our study, which represents the largest published series of pediatric syncope presenting to the ED, confirms that newly diagnosed cardiac causes of syncope are rare. Using a few specific historical features on initial interview can help guide further work-up more precisely.
Syncope is a common complaint prompting evaluation in pediatric emergency departments (EDs). The authors of a recent review describing over 70 million pediatric ED encounters reported that syncope is the chief complaint of just less than one of every 100 patients presenting to the ED. In this group of patients, cardiac causes, both previously recognized and newly diagnosed, have been estimated to provide the etiology for syncope in 1–5% of patients. Although cardiac causes of syncope are rare, they have a high recurrence rate and may be associated with significant morbidity.
The extent of the diagnostic evaluation needed for children with syncope in the ED has been a focus of discussion and research in the past, with the preponderance of the literature asserting that the history and physical examination are of greatest value when attempting to discern between cardiac and noncardiac causes of syncope. The American Heart Association published a statement on the evaluation of syncope in 2006, which stated that a "meticulous history" is of paramount importance when evaluating patients with an initial syncopal episode. However, no studies to date have clarified the precise historical features that have been associated with cardiovascular causes in pediatric patients presenting to the ED with syncope. The electrocardiogram (ECG) has been an important adjunct test in studies of syncopal children; its utility has been described previously in various cohorts, although not specifically in new ED cardiac diagnoses. Further, evaluations beyond a detailed history, physical examination, and ECG have been shown to be high cost and low yield in the evaluation of pediatric syncope. Echocardiography, as well as Holter and event monitoring, have low utility in the syncope population, with only 0.6% of echocardiograms demonstrating a potentially causative abnormality, and no abnormal monitors yielding a cardiac diagnosis in this population. Given that there is no standard work-up for the evaluation of syncope in the ED, our goals included providing data to inform such a standardized evaluation and clarifying more precisely which historical features are associated with cardiovascular causes to predict appropriate testing.
Our objectives were 1) to describe in a pediatric ED the burden of syncope due to a new cardiac diagnosis, and 2) to identify the historical features that are associated with an underlying cardiac diagnosis. We hypothesized that patients with cardiac syncope would present with at least two of the following four historical features: syncope with exercise, syncope preceded by palpitations, syncope without prodrome, or syncope with exercise preceded by chest pain.
Abstract and Introduction
Abstract
Background: The American Heart Association recommends a "meticulous history" when evaluating patients with an initial episode of syncope. However, little is known about which historical features are most helpful in identifying children with undiagnosed cardiac syncope.
Objectives: Our objectives were 1) to describe the cardiac disease burden in Emergency Department (ED) syncope presentations, and 2) to identify which historical features are associated with a cardiac diagnosis.
Methods: Using syncope presentations in our ED between May 1, 2009 and February 28, 2013, we 1) performed a cross-sectional study describing the burden of cardiac syncope, and 2) determined the sensitivity and specificity of four historical features identifying cardiac syncope.
Results: Of 3445 patients, 44.5% were male presenting at 11.5 ± 4.5 years of age. Of patients with a cardiac diagnosis (68, ~2%), only 3 (0.09%) were noted to have a previously undiagnosed cardiac cause of syncope: 2 with supraventricular tachycardia and 1 with myocarditis. Among the three cases and 100 randomly selected controls, the respective sensitivity and specificity of the historical features were 67% and 100% for syncope with exercise, 100% and 98% for syncope preceded by palpitations, and 67% and 70% for syncope without prodrome. The presence of at least two features yielded a sensitivity of 100% and specificity of 100%.
Conclusions: Our study, which represents the largest published series of pediatric syncope presenting to the ED, confirms that newly diagnosed cardiac causes of syncope are rare. Using a few specific historical features on initial interview can help guide further work-up more precisely.
Introduction
Syncope is a common complaint prompting evaluation in pediatric emergency departments (EDs). The authors of a recent review describing over 70 million pediatric ED encounters reported that syncope is the chief complaint of just less than one of every 100 patients presenting to the ED. In this group of patients, cardiac causes, both previously recognized and newly diagnosed, have been estimated to provide the etiology for syncope in 1–5% of patients. Although cardiac causes of syncope are rare, they have a high recurrence rate and may be associated with significant morbidity.
The extent of the diagnostic evaluation needed for children with syncope in the ED has been a focus of discussion and research in the past, with the preponderance of the literature asserting that the history and physical examination are of greatest value when attempting to discern between cardiac and noncardiac causes of syncope. The American Heart Association published a statement on the evaluation of syncope in 2006, which stated that a "meticulous history" is of paramount importance when evaluating patients with an initial syncopal episode. However, no studies to date have clarified the precise historical features that have been associated with cardiovascular causes in pediatric patients presenting to the ED with syncope. The electrocardiogram (ECG) has been an important adjunct test in studies of syncopal children; its utility has been described previously in various cohorts, although not specifically in new ED cardiac diagnoses. Further, evaluations beyond a detailed history, physical examination, and ECG have been shown to be high cost and low yield in the evaluation of pediatric syncope. Echocardiography, as well as Holter and event monitoring, have low utility in the syncope population, with only 0.6% of echocardiograms demonstrating a potentially causative abnormality, and no abnormal monitors yielding a cardiac diagnosis in this population. Given that there is no standard work-up for the evaluation of syncope in the ED, our goals included providing data to inform such a standardized evaluation and clarifying more precisely which historical features are associated with cardiovascular causes to predict appropriate testing.
Our objectives were 1) to describe in a pediatric ED the burden of syncope due to a new cardiac diagnosis, and 2) to identify the historical features that are associated with an underlying cardiac diagnosis. We hypothesized that patients with cardiac syncope would present with at least two of the following four historical features: syncope with exercise, syncope preceded by palpitations, syncope without prodrome, or syncope with exercise preceded by chest pain.
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