Ordering Echocardiograms for Syncope Cost Conscious Project Marvin Chang, PGY2

Objectives  Goal: To identify appropriate indications for ordering echocardiograms in patients admitted for syncope.  Estimate the cost saved by judicious ordering of echocardiograms.  To promote cost conscious practice of medicine amongst residents.

Background  Syncope is a sudden and transient loss of consciousness and postural tone. It is followed by complete and usually rapid recovery of neurological function.  Often benign and self-limited, but can be a precursor of various significant disease processes.  The cumulative incidence of syncope is 3 to 6 percent over 10 years, and 80 percent of patients have their first episode before 30 years of age  Classified by the following distribution of etiologies:  Reflex (neurally-mediated, including vasovagal) – 58%  Cardiac - most often a bradyarrhythmia or tachyarrhythmia, but also structural heart disease – 23%  Neurologic or psychiatric illness – 1%  Unexplained or unknown – 18%

Hypothesis  Guidelines advise that routine ordering of echocardiograms for syncope workup is not advised.  Hypothesize that a considerable portion of echocardiograms obtained at UCI for syncope are not actually indicated.

Initial workup for Syncope  EKG for all patients  Carotid sinus massage in patients >40 years old  Cardiac monitoring when there is a suspicion of arrhythmic syncope  Orthostatic challenge when syncope is related to the standing position or there is suspicion of a reflex mechanism.  Neurological evaluation or blood tests are less specific but indicated when there is suspicion of non-syncopal transient loss of consciousness that can mimic syncope.  Echocardiogram when there is previous known heart disease or data suggestive of structural heart disease or suspect syncope secondary to cardiovascular cause.

Indications for Echocardiogram  PMH of severe structural or coronary artery disease (heart failure, or previous myocardial infarction)  Clinical or EKG features suggesting arrhythmic syncope  Syncope during exertion or supine  Palpitations at the time of syncope  Family history of SCD  Non-sustained VT  Bifascicular-block (LBBB or RBBB combined with left anterior or left posterior fascicular block) or other intraventricular conduction abnormalities with QRS duration ≥120 ms  Inadequate sinus bradycardia (<50 bpm) or sinoartrial block in absence of negative chronotropic medications or physical training  Pre-excited QRS complex  Prolonged or short QT interval  RBBB pattern with ST-elevation in leads V1-V3 (Brugada pattern).

Design  Study population: All patients admitted to Douglas Hospital inpatient ward teams A-G and family medicine with documented episode of syncope.  Exclusion criteria: Patients with presyncope or if unclear whether syncopal episode actually occurred.  Study period: 3/23 – 4/3  Review patient’s hospitalization records including admission H&P, laboratory studies, EKG, progress notes and discharge summary.  Based on the above, determine if an echocardiogram was indicated for each patient. Then compare to whether an echocardiogram was actually ordered or not.

Results  A total of 10 patients were hospitalized for syncope between 3/23 – 4/3  6/10 patients had an echocardiogram performed  3/10 patients had indications for echocardiogram: including non sustained VT on telemetry, history of significant CAD s/p CABG, and sensation of palpitations prior to syncopal event. All patients who had indications for echo received one.  3/10 patients had an echo performed that was not indicated.  All echocardiograms ordered for syncope during this time period did not have any significant or new findings to adequately explain the syncopal episode.

Results Indication for EchoEcho orderedEcho findings Patient #1Yes – history of significant CAD with CABG YesNo significant or new findings Patient #2NoYesNo significant or new findings Patient #3No N/A Patient #4NoYesNo significant or new findings Patient #5Yes – Palpitations prior to syncopal event YesNo significant or new findings Patient #6No N/A Patient #7Yes – non-sustainted VT recorded on tele YesNo significant or new findings Patient #8No N/A Patient #9NoYesNo significant or new findings Patient #10No N/A

Discussion  Average cost of echocardiogram in the US is between $2000-$3000  Appropriately ordering echos can greatly reduce costs and ensure that patients with true indications for echos have them performed and interpreted in a more timely fashion.  $6000-$9000 over 14 days ~ $15000 a month ~ 180,000 a year  Why are echos over-ordered?  Residents are unsure of indications in general.  Vasovagal syncope is the most common cause of syncope but also somewhat of a diagnosis of exclusion.  Resident inexperience, fear of missing a diagnosis.  Pressure to discharge. If an echo is ordered early and the findings are unremarkable it might facilitate discharge.

Limitations  Small sample size  Snapshot of small time interval at UCI douglas hospital  At times there was unclear or inadequate documentation to properly determine whether an echo was indicated or not

Summary  A significant amount of cost can potentially be reduced with prudent ordering of echocardiograms.  ED staff should be educated regarding actual definition of syncope and indications for admitting syncope patients, as during the study period there were a number of patients admitted for ‘syncope’ who never actually syncopized.  Residents should be educated regarding indications for ordering echocardiograms in syncope  Overall, careful thought should be given prior to just routinely ordering echocardiograms for patients admitted for syncope.

References  Gauer, ‘Evaluation of Syncope’, Am Fam Physician Sep 15;84(6):  Olshansky, Uptodate.com, ‘Evaluation of syncope in adults’