Syncope: no ischaemic changes on the first ECG made acute cardiac ischaemia unlikely.

Clinical bottom line (level 1b)

  1. Patients with syncope were more likely to have acute cardiac ischaemia if they:
    • were male
    • had ischaemic changes on ECG in the emergency department
    • were breathless
  2. Patients with syncope were unlikely to have acute cardiac ischaemia if they had no ischaemic changes on ECG done in the emergency department.
Georgeson et al: Journal of General Internal Medicine 1992; 7: 379-386
Expires October 2004

The study

Setting: six acute hospitals, USA

251 patients (aged mean 67 years, 58% male) syncope (loss of consciousness, faint, blackout, or found on floor) or presyncope

Excluded if
  • men <30 years old, or women <40
  • chest pain


    • All patients had ECG, cardiac enzymes in the emergency department and at 48 hours.
    Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • acute cardiac ischaemia diagnosed by serial ECG, cardiac enzymes and records. ischaemic abnormality if:
      • pathological q waves
      • ST-T abnormality (elevated by 1mm or more, depressed by 0.5 mm or more)
      • T-wave abnormality (hyperacute, inverted, biphasic or flat)
      Normal if:
      • bundle branch block
      • LVH
      • early repolarisation
    Diagnostic test: clinical findings

    The evidence

    pre-test probability of acute cardiac ischaemia: .%, (95% CI: % to %)

    diagnostic test acute cardiac ischaemia no acute cardiac ischaemia LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    breathless 5 15 4.3
    (1.8 to 11)     		25% 0.77
    (0.58 to 1.0)     		6%
    arm, neck, shoulder or throat pain in the emergency department 4 130 0.40
    (0.17 to 0.95)     		3% 1.8
    (1.3 to 2.3)     		12%
    aged 65 or more 8 135 0.77
    (0.45 to 1.3)     		6% 1.3
    (0.85 to 2.1)     		9%
    male 10 31 4.2
    (2.5 to 7.1)     		24% 0.51
    (0.31 to 0.86)     		4%
    palpitations 1 22 0.59
    (0.08 to 4.1)     		4% 1.0
    (0.93 to 1.2)     		7%
    crackles on lung ausculation in the emergency department 4 47 1.1
    (0.45 to 2.7)     		8% 0.97
    (0.75 to 1.3)     		7%
    history of MI 7 37 2.5
    (1.3 to 4.7)     		16% 0.73
    (0.50 to 1.1)     		5%
    history of exercise-induced angina 6 36 2.2
    (1.1 to 4.4)     		14% 0.79
    (0.57 to 1.1)     		6%
    history of GTN use 4 34 1.5
    (0.6 to 3.8)     		11% 0.91
    (0.71 to 1.2)     		7%
    history of high glucose 3 34 1.1
    (0.39 to 3.4)     		8% 0.98
    (0.79 to 1.2)     		7%
    history of high cholesterol 1 17 0.76
    (0.11 to 5.4)     		6% 1.0
    (0.91 to 1.2)     		7%
    ischaemic abnormalities on ECG in the emergency department 18 111 2.1
    (1.8 to 2.4)     		14% 0.0
    (0.0 to 0.29)     		0%
    total 18 233

    • Five developed pyramidal signs (one stroke worsened permanently) and two had visual field losses (one permanent).
    • Stepwise logistic regression accounting for age, sex, crackles and arm pain, only ECG changes were significant.

    Citation

    1. Georgeson S, Linzer M, Griffith JL, et al: Acute cardiac ischemia in patients with syncope: importance of initial electrocardiogram. Journal of General Internal Medicine 1992; 7: 379-386
    Contributor: Chris Ball and Clare Wotton, October 2000
    Reviewer:

    Clinical Question.
    Patient syncope
    Intervention or Exposure risk factors
    Outcome acute cardiac ischaemia