Special Issue "Syncope in the Emergency Department"

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Emergency Medicine".

Deadline for manuscript submissions: closed (1 May 2021).

Special Issue Editors

Dr. Franca Dipaola
E-Mail Website
Guest Editor
1: Internal Medicine, Humanitas Clinical and Research Center - IRCCS, 20089 Rozzano, Milan, Italy; 2: Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
Interests: syncope; risk stratification; cardiovascular autonomic disorders; machine learning; evidence-based medicine
Dr. Monica Solbiati
E-Mail Website
Guest Editor
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
Interests: syncope; prognostic studies; risk stratification; evidence-based medicine; meta-analyses; critical appraisal
Dr. Emanuele Pivetta
E-Mail
Guest Editor
AOU Città della Salute e della Scienza di Torino, Turin, Italy
Interests: syncope; clinical epidemiology; diagnostic and prognostic studies; point-of-care ultrasound; evidence-based medicine

Special Issue Information

Dear Colleagues,

The management of syncope is often a challenging process for emergency physicians. Although the patient’s history, physical exam, vital signs and 12-lead electrocardiogram may lead to an etiological diagnosis in up to 50% of patients, a high percentage of them still remain undiagnosed even after a complete work up. Due to such diagnostic uncertainty and to the fear of major events in the short term, between 13% and 83% of those patients are admitted to the hospital. In most of the cases, the hospital stay does not improve diagnostic yield and leads to a significant waste of economic resources. To date, all the stratification tools developed in the last 15 years have not performed better than the physician’s clinical judgment in recognizing syncope patients at high risk for short-term adverse events.
The implementation of new management strategies and the use of new technologies could lead to the personalization and optimization of patients' diagnostic/therapeutic processes, ultimately improving the outcomes, reducing inappropriate hospitalizations and overall health care costs.
The aim of the present Special Issue is to collect reviews and original research articles that will provide practical updates and future perspectives about the management of syncope in the Emergency Department.

Dr. Franca Dipaola
Dr. Monica Solbiati
Dr. Emanuele Pivetta
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Medicina is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1500 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Syncope
  • Emergency Department
  • Diagnosis
  • Risk stratification
  • Syncope unit
  • ECG monitoring
  • Cardiac arrhythmias
  • Echocardiography
  • Biomarkers
  • Artificial intelligence

Published Papers (6 papers)

Order results
Result details
Select all
Export citation of selected articles as:

Research

Jump to: Review

Article
The Dilemma of Falls in Older Persons: Never Forget to Investigate the Syncope
Medicina 2021, 57(6), 623; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57060623 - 15 Jun 2021
Viewed by 354
Abstract
Background and objectives: Falls represent a major cause of morbidity, hospitalizations, and mortality in older persons. The identification of risk conditions for falling is crucial. This study investigated the presence of syncope as a possible cause of falls in older persons admitted [...] Read more.
Background and objectives: Falls represent a major cause of morbidity, hospitalizations, and mortality in older persons. The identification of risk conditions for falling is crucial. This study investigated the presence of syncope as a possible cause of falls in older persons admitted to a Sub-Acute Care Unit (SACU) with a diagnosis of accidental fall after initial management in an emergency department and acute hospitalization. Materials and methods: A retrospective monocentric study of patients aged ≥65 years, consecutively admitted to a SACU with a diagnosis of fall-related trauma. All patients underwent a complete assessment of the index event and clinical status. Patients were categorized into three groups according to the identified cause of falls: (1) transient loss of consciousness (T-LOC), (2) unexplained fall (UF), and (3) definite accidental fall (AF). Results: A total of 100 patients were evaluated. T-LOC was present in 36 patients, UF in 37, and AF in 27. Of the 36 patients with T-LOC, a probable origin was identified in most cases (n = 33, 91%), 19 subjects (53%) had orthostatic hypotension, 9 (25%) a cardiac relevant disturbance, 2 (6%) a reproduced vaso-vagal syncope, 2 (6%) severe anemia, and 1 (3%) severe hypothyroidism. The T-LOC group was older and more clinically complex than the other groups. Conclusion: In older patients who recently experienced a fall event, the prevalence of syncope is relevant. In frail and clinically complex patients with falls, the identification of the underlying cause is pivotal and can be achieved through prolonged monitoring and a comprehensive assessment of the person. Full article
(This article belongs to the Special Issue Syncope in the Emergency Department)
Show Figures

Figure 1

Article
Establishing a Smartphone Ambulatory ECG Service for Patients Presenting to the Emergency Department with Pre-Syncope and Palpitations
Medicina 2021, 57(2), 147; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57020147 - 06 Feb 2021
Viewed by 577
Abstract
Background and Objectives: The Investigation of Palpitations in the ED (IPED) study showed that a smartphone-based event recorder increased the number of patients in whom an electrocardiogram (ECG) was captured during symptoms over five-fold to more than 55% at 90 days compared to [...] Read more.
Background and Objectives: The Investigation of Palpitations in the ED (IPED) study showed that a smartphone-based event recorder increased the number of patients in whom an electrocardiogram (ECG) was captured during symptoms over five-fold to more than 55% at 90 days compared to standard care and concluded that this safe, non-invasive and easy-to-use device should be considered part of on-going care to all patients presenting acutely with unexplained palpitations or pre-syncope. This study reports the process of establishing a smartphone palpitation and pre-syncope ambulatory care Clinic (SPACC) service. Materials and Methods: A clinical standard operating procedure (SOP) was devised, and funding was secured through a business case for the purchase of 40 AliveCor devices in the first instance. The clinic was launched on 22 July 2019. Results: Between 22 July 2019 and 31 October 2019, 68 patients seen in the emergency departments (EDs) with palpitations or pre-syncope were referred to SPACC. Of those, 30 were male and 38 were female, and the mean age was 45.8 years old (SD 15.1) with a range from 18 years old to 80 years old. A total of 50 (74%) patients underwent full investigation. On the first assessment, seven (10%) patients were deemed to have non-cardiac palpitations and were not fitted with the device. All patients who underwent full investigation achieved symptomatic rhythm correlation most with sinus rhythm, ventricular ectopics, or bigeminy. A symptomatic cardiac dysrhythmia was detected in six (8.8%) patients. Three patients had supraventricular tachycardia (4%), two had atrial fibrillation (3%), and one had atrial flutter (2%). Qualitative feedback from the SPACC team suggested several areas where improvement to the clinic could be made. Conclusion: We believe a smartphone palpitation service based on ambulatory care is simple to implement and is effective at detecting cardiac dysrhythmia in ED palpitation patients. Full article
(This article belongs to the Special Issue Syncope in the Emergency Department)
Show Figures

Figure 1

Review

Jump to: Research

Review
Evaluation of Patients with Syncope in the Emergency Department: How to Adjust Pharmacological Therapy
Medicina 2021, 57(6), 603; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57060603 - 11 Jun 2021
Viewed by 343
Abstract
The rate of syncope in the Emergency Department ranges between 0.9 and 1.7%. Syncope is mostly related to a underlying reflex or orthostatic mechanism. A bradycardic or a hypotensive phenotype, may be identified. The latter is the most common and could be constitutional [...] Read more.
The rate of syncope in the Emergency Department ranges between 0.9 and 1.7%. Syncope is mostly related to a underlying reflex or orthostatic mechanism. A bradycardic or a hypotensive phenotype, may be identified. The latter is the most common and could be constitutional or drug induced. Consequently, obtaining an accurate drug history is an important step of the initial assessment of syncope. As anti-hypertensive medication might be responsible for orthostatic hypotension, managing hypertension in patients with syncope requires finding an ideal balance between hypotensive and cardiovascular risks. The choice of anti-hypertensive molecule as well as the therapeutic regimen and dosage, influences the risk of syncope. Not only could anti-hypertensive drugs have a hypotensive effect but opioids and psychoactive medications may also be involved in the mechanism of syncope. Proper drug management could reduce syncope recurrences and their consequences. Full article
(This article belongs to the Special Issue Syncope in the Emergency Department)
Show Figures

Figure 1

Review
Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework
Medicina 2021, 57(6), 570; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57060570 - 03 Jun 2021
Viewed by 659
Abstract
Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, research indicates that current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) [...] Read more.
Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, research indicates that current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guidelines (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders’ inputs. We then co-designed with patients and frontline teams, and developed and tested specific strategies. Results: A total of 114 clinicians completed surveys and 32 clinicians and stakeholders participated in interviews. Results from the surveys and interviews indicated low awareness of syncope guidelines, communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change as major barriers to CPG implementation. Thirty-one patients and their family caregivers participated in interviews and expressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. Identifying change methods to address the clinician barriers and patients and family caregivers expectations informed development of the multilevel, multicomponent implementation strategy, MISSION, which includes patient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and a corresponding mobile app, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Conclusions: Effective multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs. Full article
(This article belongs to the Special Issue Syncope in the Emergency Department)
Show Figures

Figure 1

Review
A Rational Evaluation of the Syncope Patient: Optimizing the Emergency Department Visit
Medicina 2021, 57(6), 514; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57060514 - 21 May 2021
Viewed by 361
Abstract
Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a [...] Read more.
Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a structured approach to the syncope patient in the emergency department, highlighting the evidence supporting the role of clinical judgement and the initial electrocardiogram (ECG) in making the preliminary diagnosis and in safely identifying the patients at low risk of short- and long-term adverse events or admitting the patient if likely to benefit from urgent intervention. Clinical decision tools and additional testing may aid in further stratifying patients and may guide disposition. While hospital admission does not seem to offer additional mortality benefit, the efficient utilization of outpatient testing may provide similar diagnostic yield, preventing unnecessary hospitalizations. Full article
(This article belongs to the Special Issue Syncope in the Emergency Department)
Show Figures

Figure 1

Review
Machine Learning and Syncope Management in the ED: The Future Is Coming
Medicina 2021, 57(4), 351; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57040351 - 06 Apr 2021
Viewed by 455
Abstract
In recent years, machine learning (ML) has been promisingly applied in many fields of clinical medicine, both for diagnosis and prognosis prediction. Aims of this narrative review were to summarize the basic concepts of ML applied to clinical medicine and explore its main [...] Read more.
In recent years, machine learning (ML) has been promisingly applied in many fields of clinical medicine, both for diagnosis and prognosis prediction. Aims of this narrative review were to summarize the basic concepts of ML applied to clinical medicine and explore its main applications in the emergency department (ED) setting, with a particular focus on syncope management. Through an extensive literature search in PubMed and Embase, we found increasing evidence suggesting that the use of ML algorithms can improve ED triage, diagnosis, and risk stratification of many diseases. However, the lacks of external validation and reliable diagnostic standards currently limit their implementation in clinical practice. Syncope represents a challenging problem for the emergency physician both because its diagnosis is not supported by specific tests and the available prognostic tools proved to be inefficient. ML algorithms have the potential to overcome these limitations and, in the future, they could support the clinician in managing syncope patients more efficiently. However, at present only few studies have addressed this issue, albeit with encouraging results. Full article
(This article belongs to the Special Issue Syncope in the Emergency Department)
Show Figures

Figure 1

Back to TopTop