CoChat
Sign Up
Cited by 192Cardiovascular Syncope and Autonomic DisordersBalance, Gait, and Falls PreventionVestibular and auditory disorders

Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients

Open access
Mallika L. Mendu, Gail McAvay, Rachel J. Lampert, Jonathan P. Stoehr, Mary E. Tinetti·2009·Archives of Internal Medicine
DOI 10.1001/archinternmed.2009.204PMC PMC3752785
Open this paper in CoChat — free accountOpen PDF

Abstract

BACKGROUND: Syncopal episodes are common among older adults; etiologies range from benign to life threatening. We determined the frequency, yield, and costs of tests obtained to evaluate older persons with syncope. We also calculated the cost per test yield and determined whether the San Francisco syncope rule (SFSR) improved test yield. METHODS: Review of 2106 consecutive patients 65 years or older admitted following a syncopal episode. RESULTS: Electrocardiograms (in 99% of admissions), telemetry (in 95%), cardiac enzyme tests (in 95%), and head computed tomographic (CT) scans (in 63%) were the most frequently obtained tests. Results from cardiac enzymes tests, CT scans, echocardiography, carotid ultrasonography, and electroencephalography all affected diagnosis or management in less than 5% of cases and helped determine the etiology of syncope less than 2% of the time. Postural blood pressure (BP) recording, performed in only 38% of episodes, had the highest yield with respect to affecting diagnosis (18%-26%) or management (25%-30%) and determining etiology of the syncopal episode (15%-21%). The cost per test affecting diagnosis or management was highest for electroencephalography ($32 973), CT scans ($24 881), and cardiac enzymes test ($22 397) and lowest for postural BP recording ($17-$20). The yields and costs for cardiac tests were better among patients meeting, vs those not meeting, the SFSR. For example, the cost per cardiac enzymes test affecting diagnosis or management was $10 331 in those meeting, vs $111 518 in those not meeting, the SFSR. CONCLUSIONS: Many unnecessary tests are obtained to evaluate syncope. Selecting tests based on history and examination and prioritizing less expensive and higher yield tests would ensure a more informed and cost-effective approach to evaluating older patients with syncope.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1001/archinternmed.2009.204

Cites

7 of 7 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The cost per informative diagnosis affecting clinical management varied widely by specific diagnostic test, from postural blood pressure ($50) through telemetry ($1,100) to EEG ($32,973).

    “The cost per informative diagnosis (as ordered in routine practice) affecting clinical management varied widely by specific diagnostic test, from postural blood pressure ($50) through telemetry ($1,100) to EEG ($32,973) (77).”

    From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [77]

    The Results report a wide variation in cost per test affecting diagnosis or management and give the cited EEG figure of $32,973. They give $17–$20 for postural blood pressure, however, not $50. The passages in our copy do not substantiate the stated $1,100 telemetry figure. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • The evidence suggests that routine neurological testing is of very limited value in the context of syncope evaluation and management; the diagnostic yield is low, with very high cost per diagnosis.

    “The evidence suggests that routine neurological testing is of very limited value in the context of syncope evaluation and management; the diagnostic yield is low, with very high cost per diagnosis (36,77,78,251–260).”

    From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [77]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Research works printed but not linked: 32

  1. [1]Kapoor WN Evaluation and management of patients with syncope JAMA 1992 268 18 2553 2560 1404823
  2. [2]Quinn J McDermott D Kramer N Death after emergency department visits for syncope: how common and can it be predicted? Ann Emerg Med 2008 5 51 5 585 90 17889403
  3. [3]Sun BC Emond JA Camargo CA Jr Characteristics and admission patterns of patients presenting with syncope to US emergency department 1992-2000 Acad Emerg Med 2004 11 10 1029 1034 15466144
  4. [4]Forman DE Lipsitz LA Syncope in the elderly Cardiol Clinics 1997 15 2 295 311 9164717
  5. [5]Gupta AK Maheshwari A Lokhandwala Y Evaluation of syncope: an overview Indian Pacing Electrophysiol J 2001 1 1 12 22 17006567 PMC1569893
  6. [7]Kapoor WN Current evaluation and management of syncope Circulation 2002 106 13 1606 1609 12270849
  7. [8]Brignole M Alboni P Benditt D Guidelines on management (diagnosis and treatment) of syncope Eur Heart J 2001 22 15 1256 1306 11465961
  8. [10]Brignole M Menozzi C Bartoletti A A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals Eur Heart J 2006 27 76 82 16272210
  9. [11]Sarasin FP Pruvot E Louis-Simonet M Stepwise evaluation of syncope: a prospective population-based controlled study Int J Cardiol 2008 127 1 103 11 17698219
  10. [12]Ammirati F Colivicchi F Santini M Diagnosing syncope in clinical practice. Implementation of a simplified diagnostic algorithm in a multicentre prospective trial - the OESIL 2 study (Osservatorio Epidemiologico della Sincope nel Lazio) Eur Heart J 2000 6 21 11 935 40 10806018
  11. [14]Grossman SA Van Epp S Arnold R The value of cardiac enzymes in elderly patients presenting to the emergency department with syncope J Geront 2003 58A 11 1055 1058 14630890
  12. [15]Link MS Lauer EP Homoud MK Wang PJ Estes NA 3rd Low yield of rule-out myocardial infarction protocol in patients presenting with syncope Am J Cardiol 2001 88 6 706 708 11564406
  13. [16]Abubakr A Wambacq I The diagnostic value of EEGs in patients with syncope Epilepsy Behav 2005 6 3 433 434 15820355
  14. [17]Grossman SA Fischer C Bar JL The yield of head CT in syncope: a pilot study Intern Emerg Med 2007 2 1 46 49 17551685 PMC2780634
  15. [18]Schnipper JL Ackerman RH Krier JB Honour M Diagnostic yield and utility of neurovascular ultrasongoraphy in the evaluation of patients with syncope Mayo Clin Proc 2005 80 4 480 488 15819284
  16. [19]Pires LA Ganji JR Jarandila R Steele R Diagnostic patterns and temporal trends in the evaluation of adult patients hospitalized with syncope Arch Intern Med 2001 161 15 1889 1895 11493131
  17. [20]Quinn JV Stiell IG McDermott DA Sellers KL Kohn MA Wells GA Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes Ann Emerg Med 2004 43 2 224 232 14747812
  18. [22]Gilbert EH Lowenstein SR Koziol-McLain J Barta DC Steiner J Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med 1996 27 3 305 308 8599488
  19. [24]Van Ness P Towle V Juthani-Mehta M Testing measurement reliability in older populations: statistical methods for reliability inference and unreliability detection J Aging Health 2008 20 2 183 197 18089767 PMC2754259
  20. [25]Kaufmann H Consensus statement on the definition of postural hypotension, pure autonomic failure and multiple system atrophy Clin Auton Res 1996 6 2 125 126 8726100
  21. [26]Naschitz JE Rosner I Orthostatic hypotension: framework of the syndrome Postgrad Med J 2007 83 983 568 574 17823222 PMC2600002
  22. [27]Masaki KH Schatz IJ Burchfiel CM Orthostatic hypotension predicts mortality in elderly men: the Honolulu Heart Program Circulation 1998 98 21 2290 2295 9826316
  23. [28]Cohen N Gorelik O Fishlev G Seated postural hypotension is common among older inpatients Clin Auton Res 2003 13 6 447 449 14673696
  24. [29]Sun BC Emond JA Camargo CA Jr Direct medical costs of syncope-related hospitalizations in the United States Am J Caridol 2005 95 5 668 671 15721118
  25. [30]Krahn AD Klein GJ Yee R Manda V The high cost of syncope: cost implications of a new insertable loop recorder in the investigation of recurrent syncope Am Heart J 1999 137 5 870 877 10220636
  26. [31]Roussanov O Estacio G Capuno M Wilson SJ Kovesdy C Jarmukli N New-onset syncope in older adults: focus on age and etiology Am J Geriatr Cardiol 2007 16 5 287 294 17786057
  27. [32]Ferguson JL Beckett GJ Stoddart M Walker SW Fox KA Myocardial infarction redefined: the new ACC/ESC definition, based on cardiac troponin, increased the apparent incidence of infarction Heart 2002 88 4 343 347 12231588 PMC1767365
  28. [33]Gould PA Krahn AD Klein GJ Yee R Skanes AC Gula LJ Investigating syncope: a review Curr Opin Cardiol 2006 1 21 1 34 41 16355027
  29. [34]Brignole M Diagnosis and treatment of syncope Heart 2007 93 1 130 136 17170354 PMC1861366
  30. [35]Wennberg JE Unwarranted variations in healthcare delivery: implications for academic medical centres BMJ 2002 325 7370 961 964 12399352 PMC1124450
  31. [36]Wennberg JE Fischer ES Skinner JS Bronner KK Extending the P4P agenda, part 2: how Medicare can reduce waste and improve the care of the chronically ill Health Aff (Millwood) 2007 26 1575 1585 17978378 PMC2213719
  32. [39]Rubenstein LZ Josephson KR The epidemiology of falls and syncope Clin Geriatr Med 2002 18 2 141 158 12180240

Cited by

Sorted by citations

Authors
Mendu, M. L., McAvay, G., Lampert, R. J., Stoehr, J. P., & Tinetti, M. E.
Affiliations
Yale University (US)
ORCID
Venue
Archives of Internal Medicine
Publisher
American Medical Association (AMA)
Published
2009-07-27
Volume
169
Issue
14
Pages
1299
ISSN
0003-9926 (ISSN-L)
DOI
10.1001/archinternmed.2009.204
PMC
PMC3752785
OpenAlex
W2121690815
Cited by
192
References
7
Citations by year
2026: 5 · 2025: 13 · 2024: 10 · 2023: 8 · 2022: 10 · 2021: 7 · 2020: 9 · 2019: 15 · 2018: 17 · 2017: 22 · 2016: 10 · 2015: 11 · 2014: 16 · 2013: 9 · 2012: 10
FWCI
10.14
Type
journal article
Language
en
Open access
Locations
  • Archives of Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • Yale University (CT 06520)
  • Raymond and Beverly Sackler Institute for Biological, Physical and Engineering Sciences, Yale University
  • National Institute on Aging (P30 AG21342, P30AG021342)
  • National Heart, Lung, and Blood Institute (R01HL089314)
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Balance, Gait, and Falls Prevention
  • Life Sciences › Neuroscience › Neurology › Vestibular and auditory disorders
Keywords
syncope, older adults, unnecessary testing, cost per test, San Francisco Syncope Rule, electrocardiogram, cardiac enzymes, head CT, syncope etiology, cost-effectiveness
MeSH terms
Aged, Aged, 80 and over, Cost-Benefit Analysis, Diagnosis, Differential, Female, Humans, Male, Risk Factors, Syncope, Diagnostic Techniques and Procedures

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review