A cross-sectional nationwide survey of guideline based syncope units in the Netherlands: the SU-19 score-a novel validation for best practices

Abstract

Aims: We aimed to identify all syncope units (SUs) in the Netherlands and assess the extent to which these SUs fulfil the essential requirements outlined by the consensus statements of the European Heart Rhythm Association and the European Society of Cardiology syncope guidelines. For this, we developed the SU-19 score, a novel guideline based validation tool for best practice.

Methods and results: All outpatient clinics of cardiology, neurology, and internal medicine in the Netherlands were screened for presence of any form of structured specialized syncope care. If present, these were included as SUs and requested to complete a questionnaire regarding syncope care. We assessed all SUs using the SU-19 score regarding structure (3 points), available tests (12 points), and initial evaluation (4 points). Twenty SUs were identified in the Netherlands, both academic (5/20) and non-academic hospitals (15/20), 17/20 reported multidisciplinary involvement during initial evaluation. In 19/20, neurology, cardiology, or both were responsible for the syncope management. Non-physicians were involved performing the head-up tilt test (44%) and initial evaluation (40%). The mean SU-19 score was 18.0 ± 1.1, 45% achieved the maximum score of 19 points. Variations were observed in protocols for active standing test, carotid sinus massage, and head-up tilt test.

Conclusion: There is a network of 20 SUs in the Netherlands. Forty-five per cent fully met the SU-19 score (mean 18.0 ± 1.1). Slight variety existed in protocols for autonomic function tests. Neurology and cardiology were mostly involved in syncope management. Non-physicians play an important role in syncope care.

Keywords: Autonomic function tests; Guideline implementation; Head-up tilt test; Network; SU-19 score; Syncope units.

Graphical Abstract

Figure 1

National overview of all academic and non-academic syncope units, their specialties involved, and their adherence areas in the Netherlands. Square blocks (□) indicate academic syncope units and circles (◯) indicate non-academic syncope units. Light grey areas indicate the adherence areas of syncope units and dark grey indicates overlap in adherence. White areas indicate that there is no formal adherence with a syncope unit. Dashed line indicates referral pattern to academic syncope unit. The image of the Netherlands is obtained from Wikipedia and the content of the municipalities has been removed and filled with light- and dark grey.

Figure 2

(A) Leading specialties for syncope care, numbers within the oval shapes indicate the specialties involved and their relative overlap, (B) who perform the initial evaluation and (C) head-up tilt tests. *Supervised by internist, **supervised by neurologist, ***supervised by cardiologist. HUT, head-up tilt test.

Figure 3

Multiple bar chart, showing an overview of the differences between syncope units regarding (A) available tests and timing, (B) active standing test, (C) carotid sinus massage, and (D) head-up tilt test. ECG, electrocardiogram; AST, active standing test; HUT, head-up tilt test; CSM, carotid sinus massage.

Figure 4

Responses shown in a spider graph for all 20 syncope units based on the syncope unit-19 score for best practices on structure (maximum of three points), diagnostic tests (maximum of 12 points), and initial evaluation (maximum of 4 points) based on European Heart Rhythm Association consensus statements one and three and the recommendations of the 2018 European Society of Cardiology guidelines on syncope. *The score on basic autonomic functions tests is specified in the Methods section. ECG, electrocardiogram; ABPM, ambulatory blood pressure monitoring.