Autonomic syncope admissions: Evaluation of current practice and application of the ESC guideline on syncope

Background The majority of syncope emergency department (ED) presentations is due to autonomic syncope, which comprises reflex syncope and orthostatic hypotension. Despite the European Society of Cardiology (ESC) guidelines many patients with autonomic syncope are still admitted. Therefore we studied the indications for, and the factors associated with, clinical admission in the prospective SYNERGY database. Methods We performed a post-hoc-analysis of patients visiting the ED with an adjudicated diagnosis of autonomic syncope from the SYNERGY database. We analyzed admission indications based on the ESC guideline risk (initial diagnosis+risk stratification); RISC-score, and clinical admission indications. We combined these admission indications and compared with observed patient management. Furthermore, we analyzed the factors associated with the decision for admission. Results We analyzed 388 adjudicated autonomic syncope patients, of whom 39.4%( n = 153) were admitted. 2.8%(11/388) had a guideline risk admission indication, 14.0%(53/388) had a RISC-score admission indication; 26.0%(101/388) had clinical admission indications. The combination of clinical indications and guideline risk yielded 26.3%(102/388) admission indications, combination with the RISC-score yielded 33.5% (130/388) for high-risk and 46.9% (182/388) for intermediate-risk admission indications. Factors associated with admission were age; diagnostics/consultations unrelated to syncope; and any ECG abnormalities without guideline ECG-risk features. In contrary, execution of an active-standing test was associated with a lower likelihood of admission. Conclusions Patients with autonomic syncope are frequently admitted to the hospital, over one-third of these admissions is not guideline-indicated. Optimizing the implementation of the guideline-based initial evaluation process may reduce unindicated admissions of autonomic syncope patients.