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. 2021 May 21;23(5):797-805.
doi: 10.1093/europace/euaa345.

Diagnostic yield and accuracy in a tertiary referral syncope unit validating the ESC guideline on syncope: a prospective cohort study

Jelle S Y de Jong  1 , Minou R Snijders Blok  1 , Roland D Thijs  2   3 , Mark P M Harms  4 , Martin E W Hemels  5   6 , Joris R de Groot  1 , Nynke van Dijk  7 , Frederik J de Lange  1
Affiliations

Diagnostic yield and accuracy in a tertiary referral syncope unit validating the ESC guideline on syncope: a prospective cohort study

Jelle S Y de Jong et al. Europace. .

Abstract

Aims: To assess in patients with transient loss of consciousness the diagnostic yield, accuracy, and safety of the structured approach as described in the ESC guidelines in a tertiary referral syncope unit.

Methods and results: Prospective cohort study including 264 consecutive patients (≥18 years) referred with at least one self-reported episode of transient loss of consciousness and presenting to the syncope unit between October 2012 and February 2015. The study consisted of three phases: history taking (Phase 1), autonomic function tests (AFTs) (Phase 2), and after 1.5-year follow-up with assessment by a multidisciplinary committee (Phase 3). Diagnostic yield was assessed after Phases 1 and 2. Empirical diagnostic accuracy was measured for diagnoses according to the ESC guidelines after Phase 3. The diagnostic yield after Phase 1 (history taking) was 94.7% (95% CI: 91.1-97.0%, 250/264 patients) and increased to 97.0% (93.9-98.6%, 256/264 patients) after Phase 2. The overall diagnostic accuracy (as established in Phase 3) of the Phases 1 and 2 diagnoses was 90.6% (95% CI: 86.2-93.8%, 232/256 patients). No life-threatening conditions were missed. Three patients died, two unrelated to the cause of transient loss of consciousness, and one whom remained undiagnosed.

Conclusion: A clinical work-up at a tertiary syncope unit using the ESC guidelines has a high diagnostic yield, accuracy, and safety. History taking (Phase 1) is the most important diagnostic tool. Autonomic function tests never changed the Phase 1 diagnosis but helped to increase the certainty of the Phase 1 diagnosis in many patients and yield additional diagnoses in patients who remained undiagnosed after Phase 1. Diagnoses were inaccurate in 9.4%, but no serious conditions were missed. This is adequate for clinical practice.

Keywords: Diagnostic accuracy; Diagnostic yield; Syncope; Transient loss of consciousness.

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Figures

Figure 1
Figure 1
The diagnostic yield and accuracy of Phase 1 (history taking) and Phase 2 (autonomic function testing) in a tertiary syncope unit sorted by physician’s certainty of the diagnosis (level of subjective probability). The levels of certainty are certain, highly likely, and possible. Left to right: the Phase 1 diagnosis after history taking sorted by subjective probability level; the Phase 2 diagnosis after autonomic testing sorted by subjective probability level; diagnostic accuracy after Phase 3 (follow-up with expert committee). Gray arrows indicate patient flow from different certainty groups. Thickness of arrows indicate relative number of patients.
Figure 2
Figure 2
A flowchart of patients through study. Percentage of patients in whom tests were performed, percentage of patients in different groups of certainty and follow-up are shown. Rates of patients in different certainty groups are shown. BP, blood pressure; ECG, electrocardiography; h, hour; ILR, implantable loop recorder.
See this image and copyright information in PMC

References

    1. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A. et al.; ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018;39:1883–948. - PubMed
    1. van Dijk N, Boer KR, Colman N, Bakker A, Stam J, van Grieken JJ. et al. High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment study. J Cardiovasc Electrophysiol 2008;19:48–55. - PubMed
    1. Brignole M, Menozzi C, Bartoletti A, Giada F, Lagi A, Ungar A. et al. A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J 2006;27:76–82. - PubMed
    1. Wieling W, Thijs RD, Linzer M, de Lange FJ, Ross A, van Dijk JG. et al. Great expectations: what patients with unexplained syncope desire. J Intern Med 2016;279:259–64. - PubMed
    1. Kenny RA, Brignole M, Dan GA, Deharo JC, van Dijk JG, Doherty C. et al.; External contributors to the Task Force. Syncope unit: rationale and requirement—the European Heart Rhythm Association position statement endorsed by the Heart Rhythm Society. Europace 2015;17:1325–40. - PubMed