Transcript Ordering Echocardiograms for Syncope

Ordering Echocardiograms for Syncope
Cost Conscious Project
Marvin Chang, PGY2
Objectives

Goal: To identify appropriate indications for ordering
echocardiograms in patients admitted for syncope.
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Estimate the cost saved by judicious ordering of
echocardiograms.
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To promote cost conscious practice of medicine amongst
residents.
Background
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Syncope is a sudden and transient loss of consciousness and postural tone. It is
followed by complete and usually rapid recovery of neurological function.
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Often benign and self-limited, but can be a precursor of various significant
disease processes.
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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%
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Cardiac - most often a bradyarrhythmia or tachyarrhythmia, but also structural
heart disease – 23%
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Neurologic or psychiatric illness – 1%
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Unexplained or unknown – 18%
Hypothesis

Guidelines advise that routine ordering of echocardiograms for syncope
workup is not advised.
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Hypothesize that a considerable portion of echocardiograms obtained at UCI
for syncope are not actually indicated.
Initial workup for Syncope
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EKG for all patients
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Carotid sinus massage in patients >40 years old
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Cardiac monitoring when there is a suspicion of arrhythmic syncope
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Orthostatic challenge when syncope is related to the standing position or
there is suspicion of a reflex mechanism.
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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.
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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
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PMH of severe structural or coronary artery disease (heart failure, or previous
myocardial infarction)
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Clinical or EKG features suggesting arrhythmic syncope
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Syncope during exertion or supine
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Palpitations at the time of syncope
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Family history of SCD
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Non-sustained VT
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Bifascicular-block (LBBB or RBBB combined with left anterior or left posterior fascicular
block) or other intraventricular conduction abnormalities with QRS duration ≥120 ms
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Inadequate sinus bradycardia (<50 bpm) or sinoartrial block in absence of negative
chronotropic medications or physical training
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Pre-excited QRS complex
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Prolonged or short QT interval
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RBBB pattern with ST-elevation in leads V1-V3 (Brugada pattern).
Design
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Study population: All patients admitted to Douglas Hospital inpatient ward
teams A-G and family medicine with documented episode of syncope.
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Exclusion criteria: Patients with presyncope or if unclear whether syncopal
episode actually occurred.
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Study period: 3/23 – 4/3
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Review patient’s hospitalization records including admission H&P, laboratory
studies, EKG, progress notes and discharge summary.
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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
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A total of 10 patients were hospitalized for syncope between 3/23 – 4/3
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6/10 patients had an echocardiogram performed
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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.
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3/10 patients had an echo performed that was not indicated.
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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 Echo
Echo ordered
Echo findings
Patient #1
Yes – history of significant Yes
CAD with CABG
No significant or new findings
Patient #2
No
Yes
No significant or new findings
Patient #3
No
No
N/A
Patient #4
No
Yes
No significant or new findings
Patient #5
Yes – Palpitations prior to
syncopal event
Yes
No significant or new findings
Patient #6
No
No
N/A
Patient #7
Yes – non-sustainted VT
recorded on tele
Yes
No significant or new findings
Patient #8
No
No
N/A
Patient #9
No
Yes
No significant or new findings
Patient #10
No
No
N/A
Discussion
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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.
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$6000-$9000 over 14 days ~ $15000 a month ~ 180,000 a year
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Why are echos over-ordered?
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Residents are unsure of indications in general.
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Vasovagal syncope is the most common cause of syncope but also somewhat of a
diagnosis of exclusion.
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Resident inexperience, fear of missing a diagnosis.
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Pressure to discharge. If an echo is ordered early and the findings are
unremarkable it might facilitate discharge.
Limitations
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Small sample size
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Snapshot of small time interval at UCI douglas hospital
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At times there was unclear or inadequate documentation to properly
determine whether an echo was indicated or not
Summary
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A significant amount of cost can potentially be reduced with prudent ordering
of echocardiograms.
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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.
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Residents should be educated regarding indications for ordering
echocardiograms in syncope
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Overall, careful thought should be given prior to just routinely ordering
echocardiograms for patients admitted for syncope.
References
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Gauer, ‘Evaluation of Syncope’, Am Fam Physician. 2011 Sep 15;84(6):640650.
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Olshansky, Uptodate.com, ‘Evaluation of syncope in adults’