Syncope & serial troponins don’t mix
Cost Containment Project
June 2015
Alex Raufi PGY2
Syncope
• Transient loss of consciousness associated with
the inability to maintain postural tone, followed
by spontaneous recovery
2009 European Society of Cardiology
Guidelines for Syncope work-up
Initial Evaluation:
1.
2.
3.
4.
History
Physical Exam
Orthostatic BP measurement
ECG
Task Force for the Diagnosis and Management of Syncope, European
Society of Cardiology (ESC), European Heart Rhythm Association
(EHRA), et al. Guidelines for the diagnosis and management of
syncope (version 2009). Eur Heart J 2009; 30:2631.
Risk Stratification
High Risk Criteria Requiring Intensive Evaluation
1.
1.
2.
3.
Severe structural disease or CAD
Heart failure
Low LVEF
Prior MI
2. Clinical or ECG features suggesting arrhythmic syncope
1.
2.
3.
4.
Syncope during exertion or while supine
Palpitations at the time of syncope
Family history of sudden cardiac death
ECG features
Task Force for the Diagnosis and Management of Syncope, European
Society of Cardiology (ESC), European Heart Rhythm Association
(EHRA), et al. Guidelines for the diagnosis and management of
syncope (version 2009). Eur Heart J 2009; 30:2631.
High yield testing
1. Carotid sinus massage (pts >40 yrs)
2. Echocardiogram
▫
▫
Known/suspected HD
Syncope 2/2 suspected cardiovascular cause
3. Telemetry
4. Orthostatic challenge
Task Force for the Diagnosis and Management of Syncope, European
Society of Cardiology (ESC), European Heart Rhythm Association
(EHRA), et al. Guidelines for the diagnosis and management of
syncope (version 2009). Eur Heart J 2009; 30:2631.
Role for Troponin in Syncope work-up?
• Troponin T:
▫ Limited diagnostic and predictive accuracy for the
identification of patients with syncope at high risk1
▫ Troponin T has a poor negative predictive value
for adverse cardiac outcomes following syncope2
• No guidelines recommend assessment of
Troponin T in the setting of syncope
1. Christ, M., et al., Diagnostic and prognostic value of highsensitivity cardiac troponin T in patients with syncope. Am J Med,
2015. 128(2): p. 161-170.e1.
2. Hing, R. and R. Harris, Relative utility of serum troponin and the
OESIL score in syncope. Emerg Med Australas, 2005. 17(1): p. 31-8.
Troponin and Syncope at UCIMC
• Study population
▫ Randomly selected patients admitted through
UCIMC ED in 2015
• Inclusion criteria
▫ Chief complaint of syncope on admission
• Exclusion criteria
▫ Patients who experienced chest pain/palpitations
• Series included total of 12 patients
Results
• 2 cases had concerning EKG findings
▫ Neither had old EKG available to compare
▫ In one case troponins were elevated, attributed to
demand ischemia
• 10 cases had no EKG changes
Results: Patients p/w syncope who had ≥1
troponin level drawn
n = 12
100%
Results: Number of times Troponin was Drawn
Number of Patients
8
7
6
5
4
3
2
1
0
0
1
2
Number times Troponin Drawn
3
Results
• Of the cases with no EKG changes NONE of the
patients had positive troponin
• None of the cases of syncope here were
attributed to ACS
Cost analysis and recommended
changes
• Monetary cost for a single troponin level
▫ $11.08 to hospital –not including phlebotomist/RN
▫ ~$400 to patient
• Nonmonetary costs
▫ Pain, time, risk of infection/complication
• 27 troponin levels drawn here for 12 patients 
$300
• Considering that 100’s of patients are seen for
syncope every week, ordering screening troponin
levels on all of them would be costly
Conclusion
• Despite a lack of evidence, patients admitted for
syncope continue to have troponin levels drawn,
increasing the cost of medicine
• Given the low pretest probability and lack of
specificity, troponin levels should NOT be drawn
for the routine work-up of syncope
Raw Data
1.
2361926 – hx of CAD s/p stent x3, RBBB - EKG: PACs - trops 3x drawn – all
neg
2. 2364346 – hx of afib, Systolic HF – EKG: Supraventricular tachycardia, old
LBBB, old - trops 3x drawn – all neg
3. 2411552 – hx of afib – EKG: afib with rvr - trops 3x drawn – all neg
4. 9074852 – EKG: a fib and left bundle branch (no prior EKGs available) - trops
3x drawn  elevated – cards consulted: demand ischemia after echo
5. 2107539 – EKG wnl - trops 3x drawn – all neg
6. 9074831 – EKG wnl - trops 3x drawn – all neg
7. 2413156 – EKG incomplete RBBB – Trop x1 drawn – neg
8. 2221815 – EKG wnl – Trop x1 drawn – neg
9. 2374345 – EKG wnl – Trop x1 drawn – neg
10. 9072503 – EKG wnl – Trop x2 drawn – all neg
11. 2401168 – EKG with minimal ST changes- trops 3x drawn – all neg
12. 2410403 – EKG wnl – Trop x1 drawn – neg