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

2. 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

3. 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

5. 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.

6. Study Design
Patients admitted to Internal Medicine Service (on Teams A-G) from 2/1/ /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

7. 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.

8. 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.

9. 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

10. 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

11. References
Shen WK, Sheldon RS, Benditt DG, et al 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:
Sarasin FP, Junod AF, Carballo D, et al. Role of echocardiography in the evaluation of syncope: a prospective study. Heart. 2002; 88:363-7.