Echocardiograms in syncope work-up April 2017 Monica Sapo, PGY2 Cost-Consciousness Project Echocardiograms in syncope work-up

Objectives To review the guidelines regarding the role of echocardiograms in the work-up of syncope and discuss indications To examine the frequency in which echocardiograms are ordered as a part of syncope work-up without indication

2017 ACC/AHA/HRS Guidelines for Evaluation of Syncope Transthoracic echocardiography (TTE) can be useful in selected patients presenting with syncope if structural heart disease is suspected

Indications for TTE in Syncope To assess the severity of the underlying cardiac disease i.e. to confirm severe aortic stenosis in patient with characteristic systolic murmur To risk stratify patients with unexplained syncope AND a positive cardiac history or an abnormal ECG Specifically to measure LVEF EF < 40% is a predictor of arrhythmias Multiple studies showed that in patients with a negative cardiac history and a normal ECG, no arrhythmias were diagnosed and echocardiography was useless.

Study Design Patients admitted to Internal Medicine Service (on Teams A-G) from 2/1/2017 - 3/30/2017 were reviewed to identify those admitted with a primary diagnosis of syncope and TTE was ordered as part of the work-up H&P, ECG, labs, diagnostic imaging and discharge summaries were reviewed Indications for ordering TTE were reviewed in selected patients

Study Design Appropriateness of ordering TTE was determined by presence of: Unexplained syncope AND Positive cardiac history (i.e CAD, murmur, documented valvular heart disease, any type of cardiomyopathy, chronic atrial fibrillation) OR Abnormal ECG (i.e. atrial fibrillation, repetitive premature ventricular contractions, bundle branch block). Non-specific ST and T wave abnormalities excluded.

Results 29 patients hospitalized for syncope 16/29 patients had TTE ordered Of those patients with TTE ordered, 50% were indicated (8/16) 2 had syncope with exertion 3 had systolic murmur on exam 3 had positive cardiac history Those that were indicated were noted to be for patients at high risk for cardiovascular causes of syncope, 2 had syncope with exertion, 3 had systolic murmur on exam and the remainder of the patients had cardiac history including CAD, and arrhythmias. *No improvement was noted when compared to 2014 Cost-consciousness project on same topic.

Discussion Charge for TTE at UCI: $1448* but locally can range from $500-5,000 Over 2 months, 8 TTEs ordered without indication (did not change management, no significant findings on study) 8 x 6 = 48 TTEs over 1 year 48 x $1448 = $69,504 per year in avoidable costs *Obtained from on 2014 Hospital Pricing Specialists Proprietary Database

Key Points Indications for TTE in syncope work-up (1) Unexplained syncope AND positive cardiac history or abnormal ECG (2) High suspicion for severe aortic stenosis Careful thought should be placed prior to ordering echocardiogram for syncope work-up as it drives up hospital and patient costs and often unnecessarily

References Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol 2017;Mar 9:[Epub ahead of print]. Recchia D, Barzilai B. Echocardiography in the evaluation of patients with syncope. J Gen Intern Med. 1995; 10:649-55. Sarasin FP, Junod AF, Carballo D, et al. Role of echocardiography in the evaluation of syncope: a prospective study. Heart. 2002; 88:363-7.