Original ContributionsApplying the Boston Syncope Criteria to Near Syncope
Introduction
Although the literature describing syncope is extensive, minimal data are available regarding the management of near syncope. Near syncope is often excluded from syncope studies or excluded due to difficulty in characterizing near syncope as well as a lack of uniform terminology 1, 2, 3. Other studies, in contrast, have not differentiated between syncope and near syncope 4, 5, 6, 7. It has been postulated that near syncope is associated with fewer comorbidities and perhaps should be considered less ominous (1). However, we have recently demonstrated that if a uniform definition of near syncope is used, patients with near syncope are as likely as patients with syncope to experience adverse outcomes (1).
Syncope accounts for approximately 1–3% of emergency department (ED) visits and up to 6% of all hospital admissions across the United States 8, 9. Hospitalization for syncope has been estimated at $5300 per stay for a total cost of over $2 billion per year nationally 8, 9, 10, 11, 12, 13, 14. As near syncope is often excluded or bundled together with syncope data, the true incidence and cost per hospitalization of near syncope is difficult to know and can only be estimated based on the outcome of syncope patients. In an environment of soaring health care costs and dwindling resources, the need for evidence-based criteria for hospitalization decision-making has become increasingly important (11). The Boston Syncope Criteria and modified Boston Syncope Criteria were designed to identify patients with syncope unlikely to have adverse outcomes and reduce hospital admission 2, 15. These criteria, as part of a clinical pathway, were able to effectively reduce hospital admissions without adverse events 2, 15. It is unclear whether these guidelines could reduce hospital admission of patients with near syncope. Given that patients with near syncope are as likely as patients with syncope to experience adverse outcomes, the objective of this study was to determine whether predefined decision criteria to reduce admission could accurately predict which patients with near syncope require hospitalization.
Section snippets
Study Design
We conducted a prospective, observational, cohort study of consecutive patients presenting with near syncope between November 2007 and August 2008. This design was similar to the design used when studying the syncope cohort (2). Institutional review board approval was received before initiation of the study, with waiver of informed consent.
Study Setting and Population
All patients presenting consecutively to the ED of a large urban teaching hospital with an annual ED census of 55,000 visits were eligible for enrollment.
Results
From October 2007 until August 2008, 1870 patients were screened for a complaint of near syncope. Two hundred forty-four patients met the study definition of near syncope; 61% were female; the average age was 56 years, SD ± 21.
There were a total of 111 admissions with 49 adverse outcomes or critical interventions. Nine of theses patients were admitted to the ED observation unit; none of these patients had adverse outcomes. Furthermore, no adverse outcomes were found in patients discharged home
Discussion
Based on our data, near-syncope patients seem safe for discharge utilizing the Boston Syncope Criteria. However, in our study we also found that near-syncope patients were less likely to be admitted than syncope patients. Therefore if Boston Syncope Criteria were followed strictly, admission rates would have been the same or slightly higher.
Previously, we found that ED patients with near syncope are as likely as patients with syncope to experience adverse outcomes and clinical interventions (1)
Conclusions
Near-syncope patients may potentially be safely discharged utilizing the Boston Syncope criteria. Although near-syncope patients may have risk factors for adverse outcomes similar to those with syncope, if the etiology of near syncope is clearly dehydration or vasovagal, and the ED work-up is otherwise normal, then these patients, like syncope patients, might be discharged even with risk factors for adverse outcome. A prospective validation study applying the modified Boston Syncope Criteria to
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Cited by (18)
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
2017, Journal of the American College of CardiologyGeriatric Syncope and Cardiovascular Risk in the Emergency Department
2017, Journal of Emergency MedicineCitation Excerpt :Admitting only those patients identified by risk factors would reduce hospital admissions by 11%–48% (20,74). Furthermore, high-risk patients who present with a benign etiology of syncope or near syncope (vasovagal or dehydration) with a normal ED work-up, would not benefit from hospitalization based on risk factors alone (26,75,76). Discharging these patients with a benign etiology and negative work-up would result in an additional 19% reduction in hospital admissions (75).
Evaluation of Syncope in Older Adults
2016, Emergency Medicine Clinics of North AmericaCitation Excerpt :The modified criteria do not take into account prior history, and in this study, patients who had a clear VVS or a hypovolemic clinical picture along with a normal ED workup were considered safe for discharge. It is important to note, however, that these results require validation.75 The key to any successful ED elder discharge is linkage with follow-up care.