Study Design Summary: Multicenter, observational study of hospitalization versus discharge on 3,000 adults ≥60 years old with no serious diagnosis found during index ED visit. Primary outcome was rate of post-ED serious adverse events.
Notes: Patients were included if ≥60 years old, presenting with either syncope or presyncope. Patients were excluded if symptoms caused by events such as intoxication, stroke, head trauma seizure or hypoglycemia, or if medical intervention such as defibrillation was needed. Testing of patients beyond baseline ECG and cardiac biomarker, troponin and BNP, testing was left up to the treating physician. The treating physician was not aware of the troponin and BNP however, but could order their own for review if felt it was needed for evaluation of the patient. Physicians were ask to give a probability that the patient would experience a 30 day cardiac event or death. It is unclear at exactly when during the encounter this was sought from the treating physicians.The researchers compared hospitalized vs discharged patients through propensity matching.
The final cohort of patients came to 2,492 total patients, from an initial 10,306 screened. While reasons were given t most of the excluded patients, 502 were listed as “other” with no explanation. There was 95 patients lost to follow up, which was relatively small. Discharged patients were generally younger, with less having CHF, CAD, or history arrhythmias.
Of the patients in the study, 75% were admitted. Mean length of stay before observation of an adverse event was 7.5 days in the admitted group, vs 13.8 days in the discharged group. The most common serious outcome was cardiac arrhythmia (36.7%). In the unadjusted analysis, the rate of serious event postdischarge was higher in the admitted group (7.4% CI 6.2-8.6 vs 3.2% 1.8-4.6 [since CI did not cross it means statistically significant]) but after propensity adjusting rates were (4.8% 3-6.7 vs 2.8% 1.4-4.2 [since CI did cross it means no statistical significance]). While it isn’t statically significant after matching, both have higher rates for the hospitalized patients, which is what hospitalization is designed to do-find the serious events, not eliminate them.
The authors draw note that the most common adverse event was arrhythmia, and while most admissions last for just a few days, in both groups the average time to serious event was over 1 week.
Study Conclusion: Hospitalization is not associated with improvement in 30 day serious adverse event rates
Fusion Beat Bottom Line Impression: This observation study draws into question whether older patients with unexplained syncope/presyncope benefit from admission. Likely shared decision making and case dependent factors are best considered when making this decision clinically at the bedside.
A Fusion Beat 