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

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 [ ]. 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 [ , , , ]. 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.