Syncope in the Pediatric Emergency Department - Can We Predict Cardiac Disease Based on History Alone?

Background: The American Heart Association recommends a "meticulous history" when evaluating patients with an initial episode of syncope. However, little is known about which historical features are most helpful in identifying children with undiagnosed cardiac syncope.

Objectives: Our objectives were 1) to describe the cardiac disease burden in Emergency Department (ED) syncope presentations, and 2) to identify which historical features are associated with a cardiac diagnosis.

Methods: Using syncope presentations in our ED between May 1, 2009 and February 28, 2013, we 1) performed a cross-sectional study describing the burden of cardiac syncope, and 2) determined the sensitivity and specificity of four historical features identifying cardiac syncope.

Results: Of 3445 patients, 44.5% were male presenting at 11.5 ± 4.5 years of age. Of patients with a cardiac diagnosis (68, ~2%), only 3 (0.09%) were noted to have a previously undiagnosed cardiac cause of syncope: 2 with supraventricular tachycardia and 1 with myocarditis. Among the three cases and 100 randomly selected controls, the respective sensitivity and specificity of the historical features were 67% and 100% for syncope with exercise, 100% and 98% for syncope preceded by palpitations, and 67% and 70% for syncope without prodrome. The presence of at least two features yielded a sensitivity of 100% and specificity of 100%.

Conclusions: Our study, which represents the largest published series of pediatric syncope presenting to the ED, confirms that newly diagnosed cardiac causes of syncope are rare. Using a few specific historical features on initial interview can help guide further work-up more precisely.