Disparities between guidelines and real-life in syncope management

Introduction: In the last 12 months two major guide-lines for the evaluation and management of syncope were published, one of the American College of Cardiology, the American Heart Association and the Heart Rhythm Association, and the newest one of the European Society of Cardiology. Also, the European Heart Rhythm Association has published a position statement on the rationale and requirement for the syncope unit. These guidelines are updating the 2009 ESC Guidelines on the management of syncope.
Objective: To determine how physicians apply these recommendations in daily practice.
Methods: We conducted a face-to-face survey research in patients (pts.) with syncope who were addressed specifically to our syncope unit to perform a Tilt table test. In this prospective study we used a consecutive sampling. The enrollment period was 5 months. We used a structured interview with closed questions on the topic „the diagnostic process before referral“. Data were analyzed using descriptive statistics.
Results: One hundred and sixty-two patients with orthostatic syncope answered the questionnaire; their characteristics were: female/male ratio=2.4/1; mean age 42.5 yrs±14.1; based on history, physical examination and ECG- 83,8% of patients had vasovagal syncope, 4.8% – situational syncope, 9.7% – orthostatic hypotension, and only one patient had a non-syncopal loss of consciousness. Though, the referral diagnostic was „syncope of unknown origin“ in 34% patients. The distribution of patients according to the specialty of the referral physician was: 12.9% – referred by cardiologists, 22.5% -emergency physicians, 12.9% – general practitioners, 48.4% – neorologists. All patients were referred after performing at least one diagnostic test; the highest number of referrals without previous diagnostic test belonged to the neurologist (6.4% patients) and the lowest to cardiologists and general practitioners (0%). However, there was a trend among neuro-logists to prescribe more than 1 diagnostic test/patient: 16.1% Holter monitoring, 12.9% cerebral CT, 22.5% EEG, 22.5% echocardiography, while the cardiologists prescribed only 3.2% Holter monitoring, 3.2% cerebral CT, and 6.4% echocardiography. After explaining the nature of their medical problem and the fact that the Tilt table test has no diagnostic role in reflex syncope with a clear diagnostic, 87% patient still chose to per-form the test in order to be reassured about their health status.
Conclusions: Our study demonstrates that the diagnosis of reflex syncope is still unclear for many prac-titioners and the direct consequence of this is the over utilization of expensive tests with very low diagnostic yield. Specific methods aimed to increase guidelines implementation, to increase diagnostic awareness and to decrease unnecessary patient anxiety are warranted.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)