Can We Discharge More Older Syncope Patients?

Written by Clay Smith

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This study suggests that we may be able to admit fewer patients ≥60 years old with unexplained syncope than we do currently. Incidence of serious adverse events was still alarmingly common in patients who were hospitalized; so, this won’t change my practice.

Why does this matter?
Recently we learned that use of the Canadian Syncope Risk Score + 2 hours of ECG monitoring in the ED was an effective way to risk stratify syncope patients in the ED. But what about older patients? Do they derive any benefit from admission?

Don’t take away that we’re now sending older patients with syncope home…
This was a secondary analysis of a prior prospectively collected dataset to determine if hospitalization of patients ≥60 with syncope benefitted from hospitalization vs discharge from the ED. Those with serious adverse events (SAE) in the ED were excluded, leaving 2,492 patients. With no statistical adjustment, patients who were hospitalized had SAE 7.4% of the time vs 3.2% in those discharged. This was largely explained, not surprisingly, by increased detection of arrhythmia in admitted patients. They then matched patients by clinical characteristics (propensity score analysis). In admitted patients with clinical characteristics matched to those who were discharged, they found no benefit to 30-day SAE rate in those who were admitted (4.89%) vs discharged (2.82%); difference 2.07% (95% CI -0.24% to 4.38%). Here is my take - with an unadjusted rate of adverse events at 7.4% in admitted patients (~5% after propensity matching), it’s hard to argue that admission is “unnecessary” in such people. However, this analysis suggests that we may be able to safely discharge more older adults with syncope than we do currently. Determining low risk is challenging. The Canadian Syncope Risk Score + 2 hours of ECG monitoring in the ED can help with risk stratification.

Source
Clinical Benefit of Hospitalization for Older Adults With Unexplained Syncope: A Propensity-Matched Analysis. Ann Emerg Med. 2019 May 9. pii: S0196-0644(19)30250-1. doi: 10.1016/j.annemergmed.2019.03.031. [Epub ahead of print]

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Reviewed by Thomas Davis

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