Keith Wrenn Always Said, “Presyncope IS Syncope.” He Was Right

July 31, 2024

Written by Caitlin Nicholson

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This systematic review found that approximately 4%-27% of patients presenting to the ED with presyncope experienced serious outcomes within a 30-day period.

Should presyncope be perceived as less worrisome than syncope?
Five articles were included in this systematic review, with the primary focus on serious short term outcomes, defined as within 30 days of presentation. Among the articles, there was variability in the short-term serious outcomes reported, with incidence ranging from 4.4% to 26.8%. Cardiac events were more common than non-cardiac, with arrhythmia being the most common serious outcome in all age groups. The most common arrhythmia subtypes were supraventricular tachycardia, sinus node dysfunction, and new or uncontrolled atrial fibrillation. The second and third most common serious outcomes were anemia/hemorrhage and myocardial infarction, respectively. 

How will this affect my practice?
I think it is reasonable, in most patient populations, to treat presyncope with as much respect as we do syncope in the emergency department. With adverse cardiac events being the most common serious outcome, using the Canadian Syncope Risk Score and cardiac biomarkers along with repeat ECGs seems to be a reasonable approach. As with most things in medicine, there is still room for provider gestalt in determining ultimate disposition for patients experiencing syncope or presyncope.

Editor’s note: I still hear Keith Wrenn in my mind on almost every shift. For the 20+ years I had the privilege of knowing him, he taught me about medicine and life, and this was one of his aphorisms: “Presyncope is syncope.” As usual, he was right. ~Clay Smith

Source
Serious outcomes among emergency department patients with presyncope: A systematic review. Acad Emerg Med. 2024 Jun 9. doi: 10.1111/acem.14943. Online ahead of print. PMID: 38853536