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Cited by 332Cardiovascular Syncope and Autonomic DisordersClinical practice guidelines implementationClinical Reasoning and Diagnostic Skills

A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals

Brignole, Michele, Menozzi, Carlo, Bartoletti, Angelo, Giada, Franco, Lagi, Alfonso, Ungar, Andrea, Ponassi, Irene, Mussi, Chiara +6 more·2006·European Heart Journal
DOI 10.1093/eurheartj/ehi647
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Abstract

AIMS: The guidelines of the European Society of Cardiology (ESC) define the current standard for the management of syncope, but are still incompletely applied in the clinical setting. METHODS AND RESULTS: Prospective systematic evaluation, on strict adherence to the guidelines, of consecutive patients referred for syncope to the emergency departments of 11 general hospitals. In order to maximize the application, a decision-making guideline-based software was used and trained core medical personnel were designated-both locally in each hospital and centrally-to verify adherence to the diagnostic pathway and give advice on its correction. A diagnostic work-up consistent with the guidelines was completed in 465/541 patients (86%). A definite diagnosis was established in 98% (unexplained in 2%): neurally mediated syncope accounted for 66% of diagnosis, orthostatic hypotension 10%, primary arrhythmias 11%, structural cardiac or cardiopulmonary disease 5%, and non-syncopal attacks 6%, respectively. The initial evaluation (consisting of history, physical examination, and standard electrocardiogram) established a diagnosis in 50% of cases. Hospitalization for the management of syncope was appropriate in 25% and was required for other reasons in a further 13% of cases. The median in-hospital stay was 5.5 days (interquartile range, 3-9). Apart from the initial evaluation, a mean of 1.9+/-1.1 appropriate tests per patient was performed in 193 patients and led to a final diagnosis in 182 of these (94%). CONCLUSION: The results of this study assess the current standard for the management of syncope on the basis of a rigorous adherence to guidelines of the ESC and provide a frame of reference for daily activity when dealing with syncope.

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Crossref · 10.1093/eurheartj/ehi647

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  • The number of syncopal events before patients were considered for ILR implantation was close to those reported from EaSyAS and EGSYS 2.

    “The number of syncopal events before patients were considered for ILR implantation was close to those reported from EaSyAS and EGSYS 2.”

    From Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry (2011) · cites this paper as [12]

    The Sample size and incidence table (p. 3) reports a median of 2 recurrent loss-of-consciousness episodes per patient, and the In-hospital pathway table (p. 6) records three implantable loop recorder recipients. It does not give the prior episode count for those patients or compare that count with EaSyAS, so the claimed similarity is not established by this paper. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • In clinical practice, registry data show that approximately 3% of patients with unexplained syncope evaluated by cardiologists undergo EPS and even fewer if they are evaluated by other specialists.

    “In clinical practice, registry data show that approximately 3% of patients with unexplained syncope evaluated by cardiologists undergo EPS and even fewer if they are evaluated by other specialists. 71”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [71]

    The Diagnostic flow table (p. 5) reports electrophysiological studies in 16 patients, or 3% of the study cohort. But that figure is not specifically for patients with unexplained syncope evaluated by cardiologists, and the paper provides no comparison with patients evaluated by other specialists. The Diagnosis section (p. 3) separately reports unexplained syncope in only 2% of patients. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • The population in PICTURE was slightly younger and healthier than those in other syncope studies such as EaSyAS, EGSYS 2, and ISSUE 2.

    “The population in PICTURE was slightly younger and healthier than those in other syncope studies such as EaSyAS,12 EGSYS 2,13 and ISSUE 2.14”

    From Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry (2011) · cites this paper as [12]

  • Most VVS patients stop fainting after assessment and without specific therapy.

    “Most patients stop fainting after assessment and in the absence of specific therapy.”

    From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [70]

    The Diagnosis section (p. 3) reports how often vasovagal syncope was identified, but not whether patients subsequently stopped fainting. The Discussion (p. 6) says the study did not collect follow-up or prognosis data, so our copy cannot verify the claimed outcome after assessment without specific therapy. (LLM, conf=0.79)

    Experimental — accuracy not yet measured

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Research works printed but not linked: 2

  1. [2]2. Ammirati F , Colivicchi F, Minardi G, De Lio L, Terranova A, Scaffidi G, Rapino S, Proietti F, Bianchi C, Uguccioni M, Carunchio A, Azzolini P , Neri R, Accogli S, Sunseri L, Orazi S, Mariani M, Fraioli R, Calcagno S, De Luca F, Santini M. Hospital management of syncope: the OESIL study. G Ital Cardiol 1999; 29 :533-539.
  2. [3]3. Disertori M, Brignole M, Menozzi C, Raviele A, Rizzon P , Santini M, Proclemer A, Tomasi C, Rossillo A, Taddei F, Scivales A, Migliorini R, De Santo T. Management of syncope referred for emergency to general hospitals. Europace 2003; 5 :283-291.

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Authors
Brignole, M., Menozzi, C., Bartoletti, A., Giada, F., Lagi, A., Ungar, A., Ponassi, I., Mussi, C., Maggi, R., Re, G., Furlan, R., Rovelli, G., Ponzi, P., & Scivales, A.
Affiliations
  • Presidio Ospedaliero (IT)
  • Santa Maria Nuova Hospital (IT)
  • Nuovo Ospedale San Giovanni di Dio (IT)
  • Azienda Ospedaliero-Universitaria Careggi (IT)
  • Ospedale Policlinico San Martino (IT)
  • University of Modena and Reggio Emilia (IT)
  • IRCCS Azienda Ospedliero-Universitaria di Bologna Policlinico di Sant'Orsola (IT)
  • University of Milan (IT)
  • Medtronic (Italy) (IT)
Corresponding author
Brignole, Michele
ORCID
Venue
European Heart Journal
Publisher
Oxford University Press (OUP)
Published
2005-11-04
Volume
27
Issue
1
Pages
76-82
ISSN
  • 0195-668X (ISSN-L)
  • 1522-9645
DOI
10.1093/eurheartj/ehi647
OpenAlex
W2162336344
Cited by
332
References
27
Citations by year
2026: 7 · 2025: 7 · 2024: 11 · 2023: 13 · 2022: 17 · 2021: 12 · 2020: 12 · 2019: 10 · 2018: 18 · 2017: 12 · 2016: 19 · 2015: 17 · 2014: 20 · 2013: 24 · 2012: 21
FWCI
16.23
Type
journal article
Language
en
Open access
closed
Locations
  • European Heart Journal (publishedVersion)
  • PubMed (publishedVersion)
  • Florence Research (University of Florence) (submittedVersion)
  • IRIS UNIMORE (University of Modena and Reggio Emilia) (submittedVersion)
  • HighWire Press Open Archive (submittedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
  • Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
Keywords
syncope, guideline adherence, diagnostic workup, neurally mediated syncope, orthostatic hypotension, emergency department management, hospitalization, ESC guidelines, diagnostic pathway
MeSH terms
Aged, Aged, 80 and over, Emergencies, Emergency Service, Hospital, Female, Hospitalization, Hospitals, General, Humans, Italy, Male, Middle Aged, Prospective Studies, Referral and Consultation, Syncope, Practice Guidelines as Topic, Guideline Adherence

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