1. ECHOs in Syncope Cost Consciousness Project Aceela Muqri, PGY-2

2. Objective To identify indications for ECHOs in patients admitted for syncopal workupTo identify indications for ECHOs in patients admitted for syncopal workup To assess whether routine ordering ECHOs in patients who are hospitalized for syncope is appropriateTo assess whether routine ordering ECHOs in patients who are hospitalized for syncope is appropriate Calculate the cost of ECHOs for the hospital in patients hospitalized for syncopal episodeCalculate the cost of ECHOs for the hospital in patients hospitalized for syncopal episode

3. Background Syncope classified as:Syncope classified as: Reflex (neurally mediated) syncopeReflex (neurally mediated) syncope Syncope due to Orthostatic hypotensionSyncope due to Orthostatic hypotension Cardiac syncope (cardiovascular)Cardiac syncope (cardiovascular)

4. Cardiogenic Syncope BradyarrythmiaBradyarrythmia Sinus node dysfunctionSinus node dysfunction AV conduction system diseaseAV conduction system disease Implanted device malfunctionImplanted device malfunction TachycardiaTachycardia SupraventricularSupraventricular ventricularventricular Drug induced bradycardia and tachyarrythmiasDrug induced bradycardia and tachyarrythmias Structural diseaseStructural disease Cardiac: cardiac vascular disease, acute MI, hypertrophic cardiomyopathy, cardiac masses, pericardial disease/tamponade, congenital anomalies, prosthetic valve dysfunctionCardiac: cardiac vascular disease, acute MI, hypertrophic cardiomyopathy, cardiac masses, pericardial disease/tamponade, congenital anomalies, prosthetic valve dysfunction Others: PE, acute aortic dissection, pulmonary hypertensionOthers: PE, acute aortic dissection, pulmonary hypertension

5. Indications for echo use in patients hospitalized for syncope Clues indicating cardiogenic cause of syncopeClues indicating cardiogenic cause of syncope Presence of definite structural heart diseasePresence of definite structural heart disease Family history of unexplained sudden cardiac death or channelopathyFamily history of unexplained sudden cardiac death or channelopathy During exertion or supineDuring exertion or supine Abnormal EKGAbnormal EKG Sudden onset palpitation immediately followed by syncopeSudden onset palpitation immediately followed by syncope

6. Indications continued EKG findings suggesting arrythmic syncopeEKG findings suggesting arrythmic syncope Bifascicular blockBifascicular block Other intraventricular conduction abnormalities (QRS >/0.12)Other intraventricular conduction abnormalities (QRS >/0.12) Mobitz second degree AV blockMobitz second degree AV block Asymptomatic inappropriate sinus bradycardia, SA block or sinus pause >/3s in the absence of negatively chronotropic medicationsAsymptomatic inappropriate sinus bradycardia, SA block or sinus pause >/3s in the absence of negatively chronotropic medications Nonsustained v tachNonsustained v tach Pre excited QRS complexesPre excited QRS complexes Long or short intervalsLong or short intervals Early repolarizationEarly repolarization RBBB pattern with ST elevation in V1-V3 (Brugada)RBBB pattern with ST elevation in V1-V3 (Brugada) Negative T waves in right precordial leadsNegative T waves in right precordial leads Q waves suggesting MIQ waves suggesting MI

7. Study Design Admissions to Medicine Teams A-GAdmissions to Medicine Teams A-G Dates: April 1, 2014- May 30, 2014Dates: April 1, 2014- May 30, 2014 Patients admitted for syncope identifiedPatients admitted for syncope identified Patient’s history/physical, laboratory results, diagnostic imaging (including EKGs), discharge summaries were reviewedPatient’s history/physical, laboratory results, diagnostic imaging (including EKGs), discharge summaries were reviewed Indications for ECHO use were identified in selected patientsIndications for ECHO use were identified in selected patients Decision to order ECHO was deemed appropriate as determined by factors concerning for cardiogenic syncopeDecision to order ECHO was deemed appropriate as determined by factors concerning for cardiogenic syncope

8. The Study Inclusion CriteriaInclusion Criteria Patients who were hospitalized for syncope and had ECHO orderedPatients who were hospitalized for syncope and had ECHO ordered Patients had full H/P, DC summary and progress notes in QuestPatients had full H/P, DC summary and progress notes in Quest Exclusion CriteriaExclusion Criteria No documented loss of consciousness (near syncope, etc)No documented loss of consciousness (near syncope, etc) Admitted to MICU, Family Medicine or other servicesAdmitted to MICU, Family Medicine or other services Transfers from OSHTransfers from OSH Transfers from other servicesTransfers from other services

9. Results 43 patients hospitalized for syncope43 patients hospitalized for syncope 21/43 patients had ECHO ordered21/43 patients had ECHO ordered 11/21 ECHOs indicated11/21 ECHOs indicated IndicationsIndications 5 arrythmia (bradyarrythmia, tachycardia)5 arrythmia (bradyarrythmia, tachycardia) 2 palpitations2 palpitations 1 abnormal EKG1 abnormal EKG 1 during exertion1 during exertion 2 known structural heart disease2 known structural heart disease 10 ECHOs not indicated10 ECHOs not indicated

10. Results/Costs 43 patients admitted for syncope in 2 months x 6= 258 patients per year43 patients admitted for syncope in 2 months x 6= 258 patients per year 10 inappropriate ECHOs in 2 months x 6= 60 inappropriate ECHOs in one year10 inappropriate ECHOs in 2 months x 6= 60 inappropriate ECHOs in one year Charge for ECHO around US $900-3300Charge for ECHO around US $900-3300 Average charge $2200Average charge $2200 $2200 x 60= $132,000 per year$2200 x 60= $132,000 per year

11. Limitations Indications for ECHO based on documented data in QuestIndications for ECHO based on documented data in Quest Small study sizeSmall study size Other services not includedOther services not included

12. Take home points Physicians should be educated regarding indications for ECHOs in syncopePhysicians should be educated regarding indications for ECHOs in syncope Careful thought should be made prior to routine ordering of ECHO for patients admitted for syncopeCareful thought should be made prior to routine ordering of ECHO for patients admitted for syncope