ECHOs in SyncopeCost Consciousness Project

Aceela Muqri, PGY-2

Objective

• To identify indications for ECHOs in patients admitted for syncopal workup

• To assess whether routine ordering ECHOs in patients who are hospitalized for syncope is appropriate

• Calculate the cost of ECHOs for the hospital in patients hospitalized for syncopal episode

Background

• Syncope classified as:• Reflex (neurally mediated) syncope• Syncope due to Orthostatic hypotension• Cardiac syncope (cardiovascular)

Cardiogenic Syncope

• Bradyarrythmia• Sinus node dysfunction• AV conduction system disease• Implanted device malfunction

• Tachycardia• Supraventricular• ventricular

• Drug induced bradycardia and tachyarrythmias

• Structural disease• Cardiac: cardiac vascular disease, acute MI, hypertrophic

cardiomyopathy, cardiac masses, pericardial disease/tamponade, congenital anomalies, prosthetic valve dysfunction

• Others: PE, acute aortic dissection, pulmonary hypertension

Indications for echo use in patients hospitalized for syncope

• Clues indicating cardiogenic cause of syncope• Presence of definite structural heart disease• Family history of unexplained sudden cardiac

death or channelopathy• During exertion or supine• Abnormal EKG• Sudden onset palpitation immediately followed

by syncope

Indications continued

• EKG findings suggesting arrythmic syncope• Bifascicular block• Other intraventricular conduction abnormalities (QRS >/0.12)• Mobitz second degree AV block• Asymptomatic inappropriate sinus bradycardia, SA block or

sinus pause >/3s in the absence of negatively chronotropic medications

• Nonsustained v tach• Pre excited QRS complexes• Long or short intervals• Early repolarization• RBBB pattern with ST elevation in V1-V3 (Brugada)• Negative T waves in right precordial leads• Q waves suggesting MI

Study Design

• Admissions to Medicine Teams A-G

• Dates: April 1, 2014- May 30, 2014

• Patients admitted for syncope identified

• Patient’s history/physical, laboratory results, diagnostic imaging (including EKGs), discharge summaries were reviewed

• Indications for ECHO use were identified in selected patients

• Decision to order ECHO was deemed appropriate as determined by factors concerning for cardiogenic syncope

The Study

• Inclusion Criteria• Patients who were hospitalized for syncope and

had ECHO ordered• Patients had full H/P, DC summary and progress

notes in Quest

• Exclusion Criteria• No documented loss of consciousness (near

syncope, etc)• Admitted to MICU, Family Medicine or other

services• Transfers from OSH• Transfers from other services

Results

• 43 patients hospitalized for syncope

• 21/43 patients had ECHO ordered

• 11/21 ECHOs indicated• Indications

• 5 arrythmia (bradyarrythmia, tachycardia)• 2 palpitations• 1 abnormal EKG• 1 during exertion• 2 known structural heart disease

• 10 ECHOs not indicated

Results/Costs

• 43 patients admitted for syncope in 2 months x 6= 258 patients per year

• 10 inappropriate ECHOs in 2 months x 6= 60 inappropriate ECHOs in one year

• Charge for ECHO around US $900-3300

• Average charge $2200

• $2200 x 60= $132,000 per year

Limitations

• Indications for ECHO based on documented data in Quest

• Small study size

• Other services not included

Take home points

• Physicians should be educated regarding indications for ECHOs in syncope

• Careful thought should be made prior to routine ordering of ECHO for patients admitted for syncope