Unexplained syncope in older patients: is hospitalization necessary?

  • Ann Emerg Med

  • International Clinical Digest
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Takeaway

  • For older emergency department (ED) patients with unexplained syncope, hospitalization was not associated with fewer adverse events in this observational study.
  • Authors: “among older adults with unexplained syncope who are not otherwise at high risk, hospitalization should not be the default pathway.”
  • Randomized trials needed.

Why this matters

  • Risk stratification for syncope is extraordinarily difficult.
  • Many patients are hospitalized for observation, to uncertain effect.

Key results

  • 1866 (74.9%) were hospitalized, most for observation.
  • 30-day serious adverse events (95% CIs):
    • Overall: 158 (6.34%; 5.38%-7.30%),
      • including 17 deaths (0.68%; 0.36%-1.01%).
    • Among hospitalized vs discharged in propensity analysis (95% CIs):
      • 4.89% (3.06%-6.72%) vs
      • 2.82% (1.41%-4.23%);
      • risk difference, 2.07% (−0.24% to 4.38%).

Study design

  • Propensity analysis of prospective multicenter observational study of adults aged ≥60 years presenting to 11 US EDs after syncope or near-syncope and with no serious diagnosis found in ED workup (n=2492).
  • Authors created a propensity-matched group of 1064, scoring each person based on 43 covariates. 
  • Outcome: 30-day rate of serious adverse events.
  • Funding: NIH.

Limitations

  • Potential residual confounding.
  • Care was not protocolized.
  • Potential sampling bias, with many eligible patients declining participation.