Diagnostic accuracy of evaluation of suspected syncope in the emergency department: usual practice vs. ESC guidelines

Veera K van Wijnen; Reinold O B Gans; Wouter Wieling; Jan C Ter Maaten; Mark P M Harms

doi:10.1186/s12873-020-00344-9

Diagnostic accuracy of evaluation of suspected syncope in the emergency department: usual practice vs. ESC guidelines

BMC Emerg Med. 2020 Aug 3;20(1):59. doi: 10.1186/s12873-020-00344-9.

Authors

Veera K van Wijnen¹, Reinold O B Gans¹, Wouter Wieling², Jan C Ter Maaten¹, Mark P M Harms³

Affiliations

¹ Department of Internal and Emergency Medicine, University of Groningen, University Medical Center Groningen, PO BOX 30001, 9700 RB, Groningen, the Netherlands.
² Department of Internal Medicine, University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands.
³ Department of Internal and Emergency Medicine, University of Groningen, University Medical Center Groningen, PO BOX 30001, 9700 RB, Groningen, the Netherlands. m.p.m.harms@umcg.nl.

Abstract

Background: Syncope 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.

Methods: This 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.

Results: One 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.

Conclusions: Usual 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.

Keywords: Diagnostic accuracy; Emergency department; Guidelines; History taking; Syncope.

MeSH terms

Diagnosis, Differential
Electrocardiography
Emergency Service, Hospital*
Female
Guideline Adherence
Humans
Male
Medical History Taking
Middle Aged
Netherlands
Physical Examination
Practice Guidelines as Topic*
Prospective Studies
Syncope / diagnosis*