ECHOs in Syncope
Cost Consciousness Project
Aceela Muqri, PGY-2
Objective
• To identify indications for ECHOs in patients admitted
for syncopal workup
• To assess whether routine ordering ECHOs in patients
who are hospitalized for syncope is appropriate
• Calculate the cost of ECHOs for the hospital in
patients hospitalized for syncopal episode
Background
• Syncope classified as:
• Reflex (neurally mediated) syncope
• Syncope due to Orthostatic hypotension
• Cardiac syncope (cardiovascular)
Cardiogenic Syncope
• Bradyarrythmia
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Sinus node dysfunction
AV conduction system disease
Implanted device malfunction
• Tachycardia
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Supraventricular
ventricular
• Drug induced bradycardia and tachyarrythmias
• Structural disease
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Cardiac: cardiac vascular disease, acute MI, hypertrophic cardiomyopathy,
cardiac masses, pericardial disease/tamponade, congenital anomalies,
prosthetic valve dysfunction
Others: PE, acute aortic dissection, pulmonary hypertension
Indications for echo use in
patients hospitalized for
syncope
• Clues indicating cardiogenic cause of syncope
• Presence of definite structural heart disease
• Family history of unexplained sudden cardiac death or
channelopathy
• During exertion or supine
• Abnormal EKG
• Sudden onset palpitation immediately followed by
syncope
Indications
continued
• EKG findings suggesting arrythmic syncope
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•
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Bifascicular block
Other intraventricular conduction abnormalities (QRS >/0.12)
Mobitz second degree AV block
Asymptomatic inappropriate sinus bradycardia, SA block or
sinus pause >/3s in the absence of negatively chronotropic
medications
Nonsustained v tach
Pre excited QRS complexes
Long or short intervals
Early repolarization
RBBB pattern with ST elevation in V1-V3 (Brugada)
Negative T waves in right precordial leads
Q waves suggesting MI
Study Design
• Admissions to Medicine Teams A-G
• Dates: April 1, 2014- May 30, 2014
• Patients admitted for syncope identified
• Patient’s history/physical, laboratory results, diagnostic
imaging (including EKGs), discharge summaries were
reviewed
• Indications for ECHO use were identified in selected
patients
• Decision to order ECHO was deemed appropriate as
determined by factors concerning for cardiogenic syncope
The Study
• Inclusion Criteria
• Patients who were hospitalized for syncope and had
ECHO ordered
• Patients had full H/P, DC summary and progress notes
in Quest
• Exclusion Criteria
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No documented loss of consciousness (near syncope, etc)
Admitted to MICU, Family Medicine or other services
Transfers from OSH
Transfers from other services
Results
• 43 patients hospitalized for syncope
• 21/43 patients had ECHO ordered
• 11/21 ECHOs indicated
• Indications
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•
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5 arrythmia (bradyarrythmia, tachycardia)
2 palpitations
1 abnormal EKG
1 during exertion
2 known structural heart disease
• 10 ECHOs not indicated
Results/Costs
• 43 patients admitted for syncope in 2 months x 6= 258
patients per year
• 10 inappropriate ECHOs in 2 months x 6= 60
inappropriate ECHOs in one year
• Charge for ECHO around US $900-3300
• Average charge $2200
• $2200 x 60= $132,000 per year
Limitations
• Indications for ECHO based on documented data in
Quest
• Small study size
• Other services not included
Take home points
• Physicians should be educated regarding indications
for ECHOs in syncope
• Careful thought should be made prior to routine
ordering of ECHO for patients admitted for syncope