Diagnostic patterns and temporal trends in the evaluation of adult patients hospitalized with syncope

Background: Syncope is a common clinical problem that is often difficult an d expensive to diagnose. We examined diagnostic patterns and trends and use of specialty consultations in the evaluation of syncope. Methods: We retrospectively reviewed the medical records of consecutive adu lt patients hospitalized with the principal diagnosis of syncope (Internati onal Classification of Diseases, Ninth Revision, code 780.2) during 1994 an d 1998 at 2 community teaching hospitals. Results: A total of 649 patients (57% female) with a mean (+/- SD) age of 6 8 +/- 15 years were identified in 1994 (n=451) and 1998 (n=198). Three hund red forty-one patients (53%) underwent at least 1 neurologic test, includin g brain computed tomographic (CT) scan (n=283), electroencephalography (n=2 53), carotid Doppler echocardiography (n=185), and brain magnetic resonance imaging (n=10). Only brain CT scan and electroencephalography yielded diag noses in 5 (2%) and 6 patients (2%), respectively with history consistent w ith seizures or stroke. Cardiovascular tests providing the highest diagnost ic yields (postural blood pressure check in 52 [30%], head-up tilt-table te st in 32 [24%], and electrophysiologic study in 5 [16%]) were used in 176 ( 27%), 132 (20%), and 31 patients (5%), respectively. Differences in the use of some tests were noted at the participating hospitals and over time (199 4 vs 1998). The total number of diagnosed cases was similar for patients un dergoing evaluation by primary care physicians alone (65/103 [63%]), compar ed with cardiology (48/85 [56%]), neurology (29/48 [60%]), or both (81/141 [57%]). After a mean (+/- SD) length of stay of 5 +/-4 days, 320 (49%) of 6 49 cases remained undiagnosed. Conclusions: Despite a reduction in the use of some tests (eg, brain CT sca n and carotid Doppler) over time, lower-yield neurologic tests were over-us ed and higher-yield cardiovascular tests were likely underused. The untarge ted, seemingly random use of specialty evaluations did not seem to contribu te to an increase in the overall number of diagnosed cases. Increased use o f specific tests directed by history and results of physical examination ma y improve diagnostic yield and decrease the cost of evaluating syncope.