Presyncope is a poorly studied symptom.
Often practitioners dismiss it or treat it like a full syncopal event, but until recently what the risks are in this population of patients in the ER was not well known.
Do you want to know what the best study to date shows on the topic?
If so read here.
If not you should, because in this well done prospective cohort study from Canada they found that 1/20 ED patients with presyncope experienced either death, cardiovascular event or Arrhythmia by 30 days from their ED visit.
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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adam.aluisio
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Nice post, but that’s a misleading conclusion you’ve chosen to include, ARA. Those who go on to read the entire paper will see that 26/40 patients with those “adverse events” were found in the ED. Many of the “serious adverse outcomes” are debatable in their “seriousness”. Even using their conservative definitions, only 13 patients (1.7%) suffered adverse outcomes after discharge (an acceptable miss rate). And, only 2 patients (both after discharge) out of the entire cohort died: 0.3%!
it is true that the majority of adverse outcomes were identified in the ED but the importance of this study is not when the diagnosis was made but rather defining a pre-test probability among ED patients presenting with this symptom.
Which at 5% (and up to 16% in sensitivity analysis) is an important prevalence to be cognizant of.
One could argue (and I would agree) that the results may not be generalizable to the ‘county’ patient cohort but it is worth thinking about…
I would say that a more (and at least equally) important finding is that when pre-syncope is managed appropriately in the ED, most significant, serious illnesses will be discovered in the ED. So, the patients who have unremarkable evaluations can then be safely and appropriately discharged.
And how about a response to how the investigators defined a “serious adverse outcome”? This is important. If some of them were not so serious, then the prevalence may need to be recalculated and may be significantly lower than 5%.
I think that is pretty true for syncope as well- that most significant illnesses can be discovered in the ED and most can be safely discharged with appropriate follow up. I find that my evaluation for presyncope and syncope are pretty much equivocal. Do you treat them differently?
I evaluate them the same, but I do consider the medicolegal implications of discharging a patient who has had true syncope different than “pre-syncope”. If the ECG is normal and there is no evidence of infection, I will often discuss the potential risks (both related to syncope and the hospitalization itself) and employ shared decision-making with the patient and/or family. If the patient has good support, and after an appropriate discussion, he/she often prefers to go home.
Do you both agree that syncope and pre-syncope are the same?
Do you both agree that syncope and pre-syncope are the same?
They are not technically the same because they have different definitions. But, I APPROACH them in the same way. Come to think about it, the term “pre-syncope” should be abolished as it leads to unnecessary conjecture.