Abstract
BackgroundSyncope is a frequent reason for referral to the emergency department. After excluding a potentially life-threatening condition, the second objective is to find the cause of syncope. The objective of this study was to assess the diagnostic accuracy of the treating physician in usual practice and to compare this to the diagnostic accuracy of a standardised evaluation, consisting of thorough history taking and physical examination by a research physician.MethodsThis prospective cohort study included suspected (pre) syncope patients without an identified serious underlying condition who were assessed in the emergency department. Patients were initially seen by the initial treating physician and the usual evaluation was performed. A research physician, blinded to the findings of the initial treating physician, then performed a standardised evaluation according to the ESC syncope guidelines. Diagnostic accuracy (proportion of correct diagnoses) was determined by expert consensus after long-term follow-up.ResultsOne hundred and one suspected (pre) syncope patients were included (mean age 59 ± 20 years). The usual practice of the initial treating physicians did not in most cases follow ESC syncope guidelines, with orthostatic blood pressure measurements made in only 40% of the patients. Diagnostic accuracy by the initial treating physicians was 65% (95% CI 56–74%), while standardised evaluation resulted in a diagnostic accuracy of 80% (95% CI 71–87%; p = 0.009). No life-threatening causes were missed.ConclusionsUsual practice of the initial treating physician resulted in a diagnostic accuracy of 65%, while standardised practice, with an emphasis on thorough history taking, increased diagnostic accuracy to 80%. Results suggest that the availability of additional resources does not result in a higher diagnostic accuracy than standardised evaluation, and that history taking is the most important diagnostic test in suspected syncope patients. Netherlands Trial Registration: NTR5651. Registered 29 January 2016,https://www.trialregister.nl/trial/5532
Highlights
Syncope is a frequent reason for referral to the emergency department
Exclusion criteria were: a) hemodynamic instability, b) in need of immediate investigations/treatment, c) psychologically, physically or cognitively unfit, d) unable to participate in the follow-up study, e) unwilling or unable to give informed consent, f) transient loss of consciousness not fitting the definition of suspected syncope, or g) a life expectancy of less than 1 year
Patient characteristics Two hundred and 18 suspected syncope patients were screened for inclusion
Summary
After excluding a potentially life-threatening condition, the second objective is to find the cause of syncope. The objective of this study was to assess the diagnostic accuracy of the treating physician in usual practice and to compare this to the diagnostic accuracy of a standardised evaluation, consisting of thorough history taking and physical examination by a research physician. Suspected syncope is a frequent presenting symptom in the dynamic setting of the Emergency Department (ED) [1]. Despite the introduction of several syncope guidelines [1, 3–5], the current strategies and diagnostic yield of syncope evaluation varies widely between physicians, hospitals and countries [6]. To improve diagnostic yield (i.e., patients receiving a working diagnosis) several studies have applied standardised clinical evaluation, which has resulted in a working diagnosis of between 63 and 95% [7–9]. The diagnostic accuracy (proportion of correct diagnoses) of initial treating physicians in usual practice is unknown [9–11]
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