Syncope in patients older than 65: do they all require admission?

Study objectives: Dogma mandates admission for most elderly patients presenting with syncope. Our objective is to characterize the national scope of practice for management of emergency department (ED) patients with syncope, with a particular emphasis on patients 65 years or older. Methods: We analyzed data from the 1997 to 2000 National Hospital Ambulatory Medical Survey, a probability sample of ED visits in the United States. Syncope was defined as a discharge diagnosis recorded as an International Classification of Diseases, Ninth Revision, Clinical Modification code of 780.2 (syncope). Patients with injury as a cause of the syncope were excluded. A subgroup analysis of patients older than 65 years was conducted. Descriptive and univariate analysis was conducted using SAS software (version 8.02). Results: Between 1997 and 2000, there were approximately 2.63 million ED patients (0.65% of all visits) with the diagnosis of syncope unrelated to injury. Mean age of syncope patients was 54.1 years versus 35.3 years for patients without syncope (P<.0001); 1.1 million patients (40.8%) were 65 years or older, and 63.8% were female patients and 82.7% were white patients. Mean waiting time to be treated by a physician was 37.2 versus 44.0 minutes (difference 6.8; 95% confidence interval [CI] 2.0 to 11.6) for syncope and nonsyncope patients, respectively; 52.9% presented by ambulance, and 40.7% were walk-in. Most patients (71.3%) received an ECG, and 36.5% of patients were monitored (86.4% and 45.2%, respectively, in patients >65 years). Computed tomographic scan was obtained in 15.1% of patients; chest radiograph was obtained in 39.8% of patients. No patients required cardiopulmonary resuscitation or died (95% CI 0 to 0.49) during their ED stay. Approximately 1 million patients (37.5%) were admitted (13.4% admissions to the ICU). Among patients older than 65 years, admission rate for syncope was 61.8% and was the sixth most common admission diagnosis. Conclusion: In contrast to standard emergency medicine teaching, syncope patients older than 65 years were often discharged from the ED, which suggests a wide variation in practice. Short-term outcome studies and a clinical pathway for management of syncope are warranted.