Written by Jason Lesnick
Spoon Feed
This secondary analysis of adults ≥40 years old with syncope or pre-syncope without a serious diagnosis made in the ED found that 5.9% of patients had a serious adverse outcome (SAO) within 30 days.
Should they stay or should they go now? Will there be trouble?
About 1–2% of all ED visits annually are for syncope or pre-syncope. Despite multiple attempts, no syncope decision rule has been definitively proven superior to clinician gestalt, so the decision to hospitalize patients for syncope is highly individualized. There is debate on the clinical and financial utility of admitting syncope and pre-syncope patients.
This secondary analysis of data prospectively collected from a U.S. multicenter observational study asked if rates and time to diagnosis of SAOs* differed significantly between hospitalized or discharged patients ≥40 years old with syncope or pre-syncope without a dangerous diagnosis identified in the ED.
1263 patients were analyzed across 6 urban US EDs from September 2020–2024 and SAOs tracked for 30 days from presentation, if discharged, or during the index hospitalization, if hospitalized.
700 patients were discharged (55.4%) compared to 563 (44.6%) who were hospitalized. 74 (5.9%) patients experienced any SAO within 30 days, including 62 (4.9%) with serious cardiac outcomes.
After propensity-score adjustment, Bayesian logistic regression showed a significant increase in diagnostic yield (OR 3.70, 95%CrI 1.85–6.82) in the hospitalized cohort relative to discharged patients, and hospitalization was associated with a shorter time to diagnosis with a HR of 12.43 (95%CI 2.94-52.48).
How will this change my practice?
This study provides fascinating data and context that will inform my shared decision-making discussions with patients whom I think need hospitalization after syncope or pre-syncope. I applaud these authors for collecting this data that we can use to advocate for indicated hospitalizations to be clinically and financially ‘worth it,’ while also helping us have higher quality shared decision-making discussions.
*SAOs were defined as death, significant cardiac arrhythmia, MI, new diagnosis of significant structural heart disease, CPR, posterior circulation stroke, sub-arachnoid hemorrhage, sepsis, pulmonary embolism, aortic dissection, acute hemorrhage requiring transfusion, cardiac intervention, or any other serious clinical event.
Source
Diagnostic Yield of Hospitalization for Emergency Department Patients With Syncope and Presyncope. Acad Emerg Med. 2026 Aug;33(8):e70393. doi: 10.1111/acem.70393. PMID: 42573572. PMCID: PMC13455808.
