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Transthoracic echocardiogram in syncope patients with normal initial evaluation: The criteria for an abnormal echocardiogram

Published:December 14, 2016DOI:https://doi.org/10.1016/j.ajem.2016.12.030
      We thank Dr. Ahmet Celik for his interest and relevant comments concerning our paper (2016 Nov 2. Pii: S0735-6757(16)30800-2. Doi 10.1016/j.ajem.2016.10.078). The reader observed that we did not discuss echocardiographic abnormalities in patients with risk factors. This concern is important because abnormal, but non-diagnostic, echocardiographic findings, irrespective of their complaint, are frequently observed in patients presenting to the emergency department. These minor echocardiographic abnormalities do not contribute to the development of syncope. Indeed, only a few findings, such as severe aortic stenosis, cardiac tamponade, and aortic dissection are indicative of syncope [
      • Task Force for the Diagnosis and management of Syncope
      • European Society of cardiology (ESC)
      • European Heart Rhythm Association (EHRA)
      • et al.
      Guidelines for the diagnosis and management of syncope (version 2009).
      ]. Thus, only limited structural heart diseases should be included in the criteria of an abnormal echocardiogram. We have considered this important point and have introduced the following echocardiographic findings to be considered as abnormal in our methods section: moderate to severe regurgitation or stenosis of any valve, severe ventricular wall hypertrophy, an ejection fraction of <45%, moderate to severe diastolic dysfunction, hypertrophic cardiomyopathy with outflow tract obstruction, severe pulmonary hypertension, regional wall motion abnormality, or marked pericardial effusion. These echocardiographic findings have been considered abnormal or diagnostic of syncope in previous studies or guideline [
      • Task Force for the Diagnosis and management of Syncope
      • European Society of cardiology (ESC)
      • European Heart Rhythm Association (EHRA)
      • et al.
      Guidelines for the diagnosis and management of syncope (version 2009).
      ,
      • Sarasin F.P.
      • Junod A.F.
      • Carballo D.
      • et al.
      Role of echocardiography in the evaluation of syncope: a prospective study.
      ,
      • Anderson K.L.
      • Limkakeng A.
      • et al.
      Cardiac evaluation for structural abnormalities may not be required in patients presenting with syncope and a normal ECG result in an observation unit setting.
      ,
      • Chang N.L.
      • Shah P.
      • Bajaj S.
      • et al.
      Diagnostic yield of echocardiography in syncope patients with normal ECG.
      ]. Echocardiographic abnormalities in the risk group of our study are presented in Table 1. However, degenerative mild stenosis or regurgitation of valve, left atrial enlargement, mild left ventricular diastolic dysfunction, aneurysmal change or dilatation of the aorta was not considered to be abnormal in our study. However, there are minimal differences between studies on the criteria to define the echocardiographic abnormalities.
      Table 1Frequency of echocardiographic abnormalities in the patients underwent transthoracic echocardiogram
      No-risk group

      (n = 47)
      Risk group

      (n = 97)
      Normal, n (%) 46 (97.9) 70 (72.2)
      Abnormal, n (%) 1 (2.1) 27 (27.8)
       Regional wall motion abnormality 0 9
       Decreased LV function
      Moderate to severe systolic (EF < 45%) 0 3
      Moderate to severe diastolic 0 2
       Valve
      Moderate to severe regurgitation 1 9
      Moderate to severe stenosis 0 1
       Hypertrophic cardiomyopathy 0 1
       Severe pulmonary hypertension 0 2
      LV, left ventricle.
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      References

        • Task Force for the Diagnosis and management of Syncope
        • European Society of cardiology (ESC)
        • European Heart Rhythm Association (EHRA)
        • et al.
        Guidelines for the diagnosis and management of syncope (version 2009).
        Eur Heart J. 2009; 30: 2631-2671
        • Sarasin F.P.
        • Junod A.F.
        • Carballo D.
        • et al.
        Role of echocardiography in the evaluation of syncope: a prospective study.
        Heart. 2002; 88: 363-367
        • Anderson K.L.
        • Limkakeng A.
        • et al.
        Cardiac evaluation for structural abnormalities may not be required in patients presenting with syncope and a normal ECG result in an observation unit setting.
        Ann Emerg Med. 2012; 60: 478-484
        • Chang N.L.
        • Shah P.
        • Bajaj S.
        • et al.
        Diagnostic yield of echocardiography in syncope patients with normal ECG.
        Cardiol Res Pract. 2016; ([7 pp.])1251637https://doi.org/10.1155/2016/1251637