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Risk-stratification tool may help avoid unnecessary echocardiography in patients with syncope

Marc A. Probst

The risk for clinically important findings on echocardiography was low when none of five predictor variables were present in adults aged at least 60 years who presented to the ED with syncope, according to a study published in the Journal of Hospital Medicine.

“The objective of this study was to develop a risk-stratification tool to identify older adults at very low risk of having a major, clinically significant finding on rest [transthoracic echocardiography] after presenting to the ED with syncope or near-syncope,” Marc A. Probst, MD, MS, associate professor in the department of emergency medicine at Mount Sinai School of Medicine, and colleagues wrote. “Using clinical, ECG and cardiac biomarker data, we created the ROMEO (Risk Of Major Echocardiography findings in Older adults with syncope) score to help optimize resource utilization for syncope.”

Researchers conducted a prospective, observational cohort study of 995 adults aged at least 60 years who presented to one of 11 EDs in the United States with syncope or near-syncope and who underwent transthoracic echocardiography between April 2013 and September 2016 (mean age, 74 years; 55% men).

The primary outcome of the study was identifying patients with a clinically significant finding on transthoracic echocardiography.

Of all patients who underwent transthoracic echocardiography, 21.6% had a major, clinically significant finding. The researchers identified five predictors associated with a major finding: a history of congestive heart failure, a history of coronary artery disease, an abnormal electrocardiogram, high-sensitivity troponin-T more than 14 pg/mL and N-terminal pro B-type natriuretic peptide greater than 125 pg/mL.

Researchers found that patients who had a score of zero on the predictor scale had an 0.8% risk for a major finding on the transthoracic echocardiography (95% CI, 0.02-4.5).

The sensitivity of a ROMEO score of 0 for excluding significant findings on echocardiography was 99.5% (95% CI, 97.4-99.9) with a specificity of 15.4% (95% CI, 13-18.1), according to the researchers, and there was a linear relationship between the ROMEO score and the probability of major findings on the transthoracic echocardiography.

“When clinicians are considering ordering an echocardiogram as part of a syncope workup, they may use the ROMEO score, along with clinical judgment, to help predict which patients are unlikely to have clinically significant findings,” Probst told Healio Internal Medicine. “Since this was a derivation study only, the ROMEO score should be validated in a separate population of ED syncope patients prior to implementation.” – by Melissa J. Webb

For more information:

Marc A. Probst, MD, MS, can be reached at mprobst@gmail.com.

Disclosure: Probst reports receiving support from the National Heart, Lung, and Blood Institute of the National Institutes of Health.