Syncope & serial troponins don’t mix Cost Containment Project June 2015 Alex Raufi PGY2

Syncope Transient loss of consciousness associated with the inability to maintain postural tone, followed by spontaneous recovery

2009 European Society of Cardiology Guidelines for Syncope work-up Initial Evaluation: 1.History 2.Physical Exam 3.Orthostatic BP measurement 4.ECG Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631.

Risk Stratification High Risk Criteria Requiring Intensive Evaluation 1.Severe structural disease or CAD 1.Heart failure 2.Low LVEF 3.Prior MI 2.Clinical or ECG features suggesting arrhythmic syncope 1.Syncope during exertion or while supine 2.Palpitations at the time of syncope 3.Family history of sudden cardiac death 4.ECG features Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631.

High yield testing 1.Carotid sinus massage (pts >40 yrs) 2.Echocardiogram ▫Known/suspected HD ▫Syncope 2/2 suspected cardiovascular cause 3.Telemetry 4.Orthostatic challenge Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631.

Role for Troponin in Syncope work-up? Troponin T: ▫Limited diagnostic and predictive accuracy for the identification of patients with syncope at high risk 1 ▫Troponin T has a poor negative predictive value for adverse cardiac outcomes following syncope 2 No guidelines recommend assessment of Troponin T in the setting of syncope 1. Christ, M., et al., Diagnostic and prognostic value of high- sensitivity cardiac troponin T in patients with syncope. Am J Med, (2): p e1. 2. Hing, R. and R. Harris, Relative utility of serum troponin and the OESIL score in syncope. Emerg Med Australas, (1): p

Troponin and Syncope at UCIMC Study population ▫Randomly selected patients admitted through UCIMC ED in 2015 Inclusion criteria ▫Chief complaint of syncope on admission Exclusion criteria ▫Patients who experienced chest pain/palpitations Series included total of 12 patients

Results 2 cases had concerning EKG findings ▫Neither had old EKG available to compare ▫ In one case troponins were elevated, attributed to demand ischemia 10 cases had no EKG changes

Results: Patients p/w syncope who had ≥1 troponin level drawn

Results: Number of times Troponin was Drawn

Results Of the cases with no EKG changes NONE of the patients had positive troponin None of the cases of syncope here were attributed to ACS

Cost analysis and recommended changes Monetary cost for a single troponin level ▫$11.08 to hospital –not including phlebotomist/RN ▫~$400 to patient Nonmonetary costs ▫Pain, time, risk of infection/complication 27 troponin levels drawn here for 12 patients  $300 Considering that 100’s of patients are seen for syncope every week, ordering screening troponin levels on all of them would be costly

Conclusion Despite a lack of evidence, patients admitted for syncope continue to have troponin levels drawn, increasing the cost of medicine Given the low pretest probability and lack of specificity, troponin levels should NOT be drawn for the routine work-up of syncope

Raw Data – hx of CAD s/p stent x3, RBBB - EKG: PACs - trops 3x drawn – all neg – hx of afib, Systolic HF – EKG: Supraventricular tachycardia, old LBBB, old - trops 3x drawn – all neg – hx of afib – EKG: afib with rvr - trops 3x drawn – all neg – EKG: a fib and left bundle branch (no prior EKGs available) - trops 3x drawn  elevated – cards consulted: demand ischemia after echo – EKG wnl - trops 3x drawn – all neg – EKG wnl - trops 3x drawn – all neg – EKG incomplete RBBB – Trop x1 drawn – neg – EKG wnl – Trop x1 drawn – neg – EKG wnl – Trop x1 drawn – neg – EKG wnl – Trop x2 drawn – all neg – EKG with minimal ST changes- trops 3x drawn – all neg – EKG wnl – Trop x1 drawn – neg