Correlation of noninvasive electrocardiography with invasive electrophysiology in syncope of unknown origin: implications from a large syncope database

Abstract

Background: The evaluation of syncope can be expensive, unfocussed, and unrevealing yet, failure to diagnose an arrhythmic cause of syncope is a major problem. We investigate the utility of noninvasive electrocardiographic evaluation (12-lead ECG and 24-hour ambulatory electrocardiographic recordings) to predict electrophysiology study results in patients with undiagnosed syncope.

Methods: We evaluated 421 patients with undiagnosed syncope who had an electrocardiogram (ECG), an electrophysiology study, and 24-hour ambulatory monitoring. Noninvasive testing was used to predict electrophysiology testing outcomes. Multivariable logistic regression analysis adjusting for age, sex, presence of heart disease, and left ventricular ejection fraction (LVEF) was used to assess independent predictors for sinus node disease, atrioventricular node disease, and induction of ventricular tachyarrhythmias.

Results: Patients were divided into four groups: group 1, abnormal ECG and ambulatory monitor; group 2, abnormal ECG only; group 3, abnormal ambulatory monitor; and group 4, normal ECG and ambulatory monitor. The likelihood of finding at least one abnormality during electrophysiologic testing among the four groups was highest in group 1 (82.2%) and lower in groups 2 and 3 (68.1% and 33.7%, respectively). In group 4, any electrophysiology study abnormality was low (9.1%). Odds ratios (OR) were 35.9 (P < 0.001), 17.8 (P < 0.001), and 3.5 (P = 0.064) for abnormal findings on electrophysiology study, respectively (first three groups vs the fourth one). ECG and ambulatory monitor results predicted results of electrophysiology testing.

Conclusion: Abnormal ECG findings on noninvasive testing are well correlated with potential brady- or/and tachyarrhythmic causes of syncope, in electrophysiology study of patients with undiagnosed syncope.

Figure 1

Results of electrophysiology study (EPS) in the four patients groups. *P value after chi‐square test of each group with the fourth one.

Figure 2

Proportion of patients with electrophysiologic study (EPS) evidence of atrioventricular node disease (AVND) among the syncope of unknown origin (SUO) patients with different conduction defects.

Figure 3

Proportion of syncope of unknown origin (SUO) patients with either instantaneous sinus bradycardia (SB) on electrocardiogram (ECG), or combined SB on both ECG and 24‐hour Holter monitoring (HM) who had electrophysiologic study (EPS) evidence of sinus node disease (SND).