Syncope - Low-Risk, 2h ECG Monitor, Home?

Written by Clay Smith

Spoon Feed
A low-risk Canadian Syncope Risk Score (CSRS) plus 2 hours of ECG monitoring in the ED was able to identify 99.8% of patients at low risk for 30-day serious arrhythmic outcome (SAO).

Why does this matter?
Risk stratification of syncope patients has proven difficult. The San Francisco Syncope Rule initially looked good, but subsequent studies failed to replicate its diagnostic accuracy. Would the Canadian Syncope Risk Score + ECG monitoring help risk stratify patients?

Low-risk, 2h on the monitor, home
This was a prespecified secondary analysis of the RiSEDS study to determine the optimal duration of ECG monitoring in patients with syncope. In this prospective multicenter study, 5,581 patients with syncope were enrolled and risk stratified with the CSRS. Of these, 207 (3.7%) had a SAO (death, device implanted, or diagnosed arrhythmia). The rule alone performed well. Of the 74% classified as having a low-risk score, 15 (0.4%) had SAO; 19% were scored medium-risk and 92 (8.7%) had SAO; of the 7.1% scored high-risk, 100 (25.3%) had SAO. They determined the optimal cut point for ECG monitoring in the ED for CSRS low-risk patients was 2 hours, with only 0.2% having 30-day SAO. None of the SAO in the low-risk cohort included ventricular arrhythmia or death. In patients who scored medium to high-risk, 6 hours of monitoring in the ED reduced the risk of 30-day SAO to 5% and 18.1%, respectively. The CSRS plus tailored monitoring could help us identify a very low risk group who is safe for discharge and a cohort with higher risk who could either be selectively admitted or have outpatient monitoring arranged.

Another Spoonful
EM Cases has an outstanding podcast on pediatric and adult syncope.

Source
Duration of Electrocardiographic Monitoring of Emergency Department Patients with Syncope. Circulation. 2019 Jan 21. doi: 10.1161/CIRCULATIONAHA.118.036088. [Epub ahead of print]

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