Screening rule differentiates between vasovagal and cardiac syncope

Screening children and adolescents who experience syncope using characteristics in the history, physical exam, and electrocardiogram (ECG) accurately identifies which patients require further evaluation for cardiac problems, a new study concluded. Investigators retrospectively compared data for 106 patients aged between 4 to 18 years who visited an outpatient cardiology facility or an emergency department (ED) with either vasovagal syncope (89 patients) or cardiac syncope (17 patients).

Investigators compared a wide range of characteristics of those with vasovagal syncope versus those with cardiac syncope, including circumstances surrounding the syncopal event, signs and symptoms during the event, medical history, and cardiology evaluation findings. They found 4 characteristics that are far more likely in patients with cardiac syncope than in patients with more benign vasovagal syncope:

•  Syncope related to activity (identified in 65% of those with cardiac syncope vs 18% of those with vasovagal syncope);

•  Family history of cardiac disease or sudden cardiac death (41% vs 25%, respectively);

•  Abnormal findings on the physical examination supporting a cardiac diagnosis (29% vs 0%, respectively);

•  Abnormal findings on ECGs (76% vs 0%, respectively).

Screening for cardiac disease using any 1 of these 4 characteristics had a sensitivity of 100% and specificity of 60%. About 60% of patients in the study with vasovagal syncope would not have been referred to cardiology had this screening rule been applied, the investigation determined (Tretter JT, et al. J Pediatr. 2013;163[6]:1618-1623).

COMMENTARY  Worrisome cardiac syncope is much less common than vasovagal syncope. In this study, researchers collected data on 89 patients with vasovagal syncope by evaluating 1 year’s referrals to their cardiology clinic. To find 17 patients with cardiac syncope, they reviewed charts from 10 years of visits to their ED, inpatient service, and cardiology clinic. The findings of this study may allow you to avoid a cardiology referral for most of the children you see after what seems to you to be a simple vasovagal fainting episode. -Michael Burke, MD

MS FREEDMAN is a freelance medical editor and writer in New Jersey. DR BURKE, section editor for Journal Club, is chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore, Maryland, and physician contributing editor for Contemporary Pediatrics. The editors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.