Syncope: The IRiS Study – Not for the Faint of Heart

Dr. Sinert graciously hosted Food & Journal this week at his outdoor courtyard in Brooklyn. Over barbecue and veggies, we spent the first half of the night discussing a new paper on syncope management and the second cheering Usain Bolt to a speedy Olympic victory with some choice cupcakes from a local Brooklyn bakery.

The paper we discussed is an accepted article for Academic Emergency Medicine from Europe and our Italian EM colleagues. The IRiS (Intermediate-Risk Syncope) Study was conducted in 2013 at the Academic Hospital of Parma.

As we all know, syncope is seen in most ER shifts. Prior studies from Boston and San Francisco have established rules showing that anemic patients or those with cardiac disease are at risk of morbidity and mortality when discharged. This paper sought to further evaluate the idea of cardiac disease. They identified those with stable cardiac disease as intermediate risk and looked at the decision to discharge. You can envision these patients. Your chronic “hypertensive” with one stent who looks great with a normal ECG who tells you about how after no breakfast and poor sleep, he stood up this morning and after a rush of warmth, fainted and is now in your ED. Sounds vasovagal, he looks great, but doesn’t a stent suggest cardiac disease, even if stable? Can you discharge him? Should he be in the observation unit? Admitted for a work up?

The IRiS study enrolled around 1,000 syncope patients. After excluding those who syncopized from a new underlying diagnosis (PNA, UTI, etc.) and low risk patients (<50 yo, nl ECG, nl exam and “vasovagal story”), the authors were left with 347 patients. 97 of these were high-risk (decompensating heart disease, systolic murmurs, exertional syncope, or abnormal ECG – AV block, QTc changes, bifascicular blocks or Brugada). The remaining 250 were categorized as “intermediate-risk”.

For the 97 “high-risk” patients, there were 27 adverse events (3 deaths, 5 major CV events, 1 major bleed and 18 AICDs, pacemakers, or ablations). For the 250 “intermediate risk” patients there were only 2 adverse events (one AFib with a stroke and one pacemaker placed for sick sinus syndrome). Of these 250 “intermediate-risk” patients, 98 were admitted, 59 were placed on ED observation and 93 were discharged. The ED observation patients stayed 6 days less than the admitted patients (1.7 vs. 8.8 days) with a cost savings of $2,500 ($432 vs. $2,969) and interestingly, a higher likelihood of a diagnostic explanation for their syncope (71.2% vs. 49%), all differences which were statistically significant.

The authors concluded from the results that there is a low rate of adverse events in “intermediate-risk” syncope. They note that these patients could likely be discharged, and this would save patients’ time and society’s resources. There were limitations to this conclusion. (1) High-risk patients had many “elective” adverse events as 18 of the 27 events were due to implanted devices overstating the actual risk, and (2) ED observation patients were less “sick” than admitted patients (i.e. selection bias). The authors noted that what was really needed was a prospective, interventional study to further study discharged patients.

Over dinner, we discussed personal factors that lead each of us to admit patients with syncope. We agreed with the need for admission of “high-risk” patients with actively worsening cardiac disease. We commiserated with the shortened length of stay in ED observation (our own unit quickly obtains serial troponins, an echo and a cardiology consult with discharge in a day) versus medical admission (we often round on “admitted for ACS r/o MI” patients who were admitted over a week ago).

Lastly, we agreed that the study we really wanted to see was a prospective one that looked at outcomes for discharged patients versus all others. We noted that discharge often avoids hospital-related complications. M&M often focuses on the missed diagnosis in a discharged patient and rarely on the adverse hospital events that occur in patients who are unnecessarily admitted. We discussed how this could lead to an “admission bias” for physicians, an interesting idea to consider when deciding to admit.

As the night ended and Usain Bolt sped to victory, we thanked each other for the discussion and agreed to do it all over again next month at a yet undisclosed location in Brooklyn. We look forward to food, friends, and good discussion in the future.

Until next time, ladies & gentleman,

The Original Kings of County

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