I -Real-world problems in the management of syncope
a) Great inter-hospital variability - management of syncope depends on the attitude of the staff
A prospective observational registry from a sample of 28 general hospitals was performed in Italy in order to evaluate the impact of the guidelines of the European Society of Cardiology (1) on usual practice of management of syncope admitted in emergency. The Evaluation of Guidelines in Syncope Study 1 (EGSYS-1) (2) enrolled all consecutive patients referred to their emergency rooms from November 5th 2001 to December 7th 2001 who were affected by transient loss of consciousness as the principal symptom. The findings of each of the 28 hospitals participating in the survey were evaluated separately.
The authors observed great inter-hospital and inter-department heterogeneity regarding the incidence of emergency admission, in-hospital pathways, most of the examinations performed and the final assigned diagnosis. As a consequence of the great inter-hospital variability, the authors were unable to describe a uniform strategy for the management of syncope in the usual practice. This heterogeneity was minimally explained by a difference in the clinical characteristics of the population referred to the hospitals participating in the study. Indeed, the proportion of explained variability was calculated to be less than 10% of total variance.
Thus, the authors concluded that the main determinant of this different behavior lies in the different attitudes of the staff.
b) Guidelines are unlikely to change this situation because they are not known nor followed well enough
Assuming the status quo of the syncope evaluation is left as is, diagnostic and treatment effectiveness is unlikely to improve substantially. Even the implementation of the published syncope management guidelines is likely to be diverse, uneven in its application, and of uncertain benefit.
Guidelines from scientific societies should provide the standard, but guidelines are poorly known and sometimes difficult to be applied in clinical practice and physicians of specialities different from those which made the guideline are reluctant to apply it to their patients. Thus, guidelines alone can hardly change usual practice.
II - Existing models of Syncope Management Units : from the one stop sycope facility to the multi-faceted practice
Models of delivery of care vary from a single ‘one site – one stop’ syncope facilities to a wider based multi-faceted practice where a number of specialists are involved in syncope management.
1 - The Day Case Syncope Evaluation Unit adopted by the Newcastle group is a multidisciplinary approach to referrals with syncope or falls, especially dedicated to elderly people, in a strict relationship with the Accident and Emergency Department. All patients attend the same facility (with access to cardiovascular equipment, investigations and trained staff) but are investigated by a geriatrician or cardiovascular physician according to the dominant symptom cited in referral correspondence - falls or syncope.
Recently, this group showed significant savings in emergency hospital costs. The savings were attributed to a combination of factors - reduced re-admission rates, rapid access to day case facilities for accident and emergency staff and community physicians, and reduced event rates because of effective targeted treatment strategies for syncope and falls (3).
2 - A recent randomised, single center study (4) showed that a Syncope Observational Unit in an Emergency Department, with appropriate resources and a multi-disciplinary collaboration, could improve the diagnostic yield, reduce hospital admission, and achieve favorable long term outcome in survival and recurrent symptoms of syncope.
After initial assessment with a complete history, physical examination and standard electrocardiogram the patients received continuous cardiac telemetry for up to 6 hours, hourly vital signs and orthostatic blood pressure checks, and echocardiogram for patients with abnormal cardiovascular examination or electrocardiographic findings. Tilt table testing, carotid sinus massage, and electrophysiology consultations (and other subspecialities) were made available to the emergency physician. After completion of syncope observational unit evaluation, follow-up appointment at the outpatient syncope management unit can be arranged, when needed, if the patient is not to be admitted to the hospital.
3 - The service model adopted in some Italian hospitals (5) is a functional Syncope Management Unit managed by cardiologists inside the department of cardiology, with dedicated medical and support personnel.
The patients attending this Syncope Unit have preferential access to all the other facilities and investigations within the department including admission to cardiology wards or the intensive care unit if indicated. Where appropriate, patients are jointly managed with other specialists, i.e neurologists. The patients are referred to the unit from the emergency department as well from in-patient or out-patient clinics but the personnel of the unit are not usually involved in the initial evaluation of the patient. This model substantially improved the overall management of syncope compared to peer hospitals without such a facility (6).
3 - A model of Comprehensive (“Hub”) Syncope Management Unit which is able to provide a global assessment of the patient with syncope within the hospital is proposed in Figure (7). In this model, the single physician or the team of physicians who lead the syncope facility take care of a compehensive management of the patient from risk stratification to diagnosis, therapy and follow-up.
III - The standards recommended by the ESC guidelines
It is probably not appropriate to be dogmatic in this field. For this reason, ESC guideliens (1,2) do not provide recommendations but only a framework of general standards within which each physician can set up in the model of Syncope Unit which is best for his or her hospital (as are the examples shown above).
In a single dedicated facility the skill mix will depend on the specialty designated to take a lead in the development of the facility. There are existing models where cardiologists (commonly with an interest in cardiac pacing and electrophysiology), neurologists (commonly with an interest in autonomic disorders and/or epilepsy), general physicians and geriatricians (with an interest in age-related cardiology or falls) have lead syncope facilities. There is no evidence for superiority of any model. One factor which will influence the skill mix (ie, the types of professionals/expertise required to staff the facility) is the extent to which screening of referrals occurs prior to presentation at the facility. If referrals hail directly from the community and/or from the accident and emergency department, a broader skill mix is required. Under these circumstances, other differential diagnoses such as epilepsy, neuro-degenerative disorders, metabolic disorders and falls are more likely to be referred. Core medical and support personnel should be involved full time or most of the time in the management of the Unit and should interact with all other stakeholders in the hospital and in the community.
Core equipment for the syncope evaluation facility include: surface ECG recording, phasic blood pressure monitoring, tilt table testing equipment, external and internal (implantable) ECG loop recorder systems, 24 hour ambulatory blood pressure monitoring, 24 hour ambulatory ECG monitoring, and autonomic function testing. The facility should also have access to echocardiography, intracardiac electrophysiologic testing, stress testing, cardiac imaging, computed tomagraphy and magnetic resonance imaging head scans and electroencephalography.
Patients should have preferential access to hospitalisation and to any eventual therapy for syncope, namely pacemaker and defibrillator implantation, catheter ablation of arrhythmias, etc.
Dedicated rooms for assessment and investigation are required.
The majority of syncope patients can be investigated as out-patients or day cases. A major objective of the syncope facility is to reduce the number of hospitalisations by offering the patient a well defined, quick, alternative evaluation pathway.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.