Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://www.cardiologyres.org

Original Article

Volume 9, Number 4, August 2018, pages 197-203

Utilization of Echocardiogram, Carotid Ultrasound, and Cranial Imaging in the Inpatient Investigation of Syncope: Its Impact on the Diagnosis and the Patient’s Length of Hospitalization

Figure 1. Interval plot of hospital length of stay (LOS) in correlation with number of imaging test ordered. LOS: length of stay. The pooled standard deviation was used to calculate the intervals.

**Table 1.** Baseline Characteristics, Comorbidities, and Home Medications of Patients Admitted for Syncope
	N = 109(%)
Age	68.74 ± 21.04 years
Male	43 (39.44%)
Female	66 (60.55%)
Race
White	72 (66.05%)
Black	18 (16.51%)
Hispanic	13 (11.92%)
Asian	4 (3.66%)
Other	2 (1.83%)
Common Comorbidities
Hypertension	69 (63.30%)
Hyperlipidemia	35 (32.11%)
Coronary artery disease	22 (20.18%)
Hypothyroidism	18 (16.82%)
Diabetes mellitus	17 (15.59%)
Atrial fibrillation	15 (16.51%)
Anemia	15 (13.76%)
Cerebrovascular accident	11 (10.09%)
Chronic kidney disease	11 (10.09%)
Dementia	11 (10.09%)
Common Medications
Statin	37 (33.94%)
Antiplatelet	37 (33.94%)
Beta blocker	36 (33.02%)
Calcium channel blocker	32 (29.35%)
Multivitamins	23 (21.10%)
Angiotensin converting enzyme inhibitor	22 (20.18%)
Selective serotonin reuptake inhibitor	20 (18.34%)
Thyroid hormone	19 (17.43%)
Angiotensin receptor block	15 (13.76%)
Anticonvulsant	13 (11.92%)

Table 1. Baseline Characteristics, Comorbidities, and Home Medications of Patients Admitted for Syncope

N = 109(%)

Age

68.74 ± 21.04 years

Male

43 (39.44%)

Female

66 (60.55%)

Race

White

72 (66.05%)

Black

18 (16.51%)

Hispanic

13 (11.92%)

Asian

4 (3.66%)

Other

2 (1.83%)

Common Comorbidities

Hypertension

69 (63.30%)

Hyperlipidemia

35 (32.11%)

Coronary artery disease

22 (20.18%)

Hypothyroidism

18 (16.82%)

Diabetes mellitus

17 (15.59%)

Atrial fibrillation

15 (16.51%)

Anemia

15 (13.76%)

Cerebrovascular accident

11 (10.09%)

Chronic kidney disease

11 (10.09%)

Dementia

11 (10.09%)

Common Medications

Statin

37 (33.94%)

Antiplatelet

37 (33.94%)

Beta blocker

36 (33.02%)

Calcium channel blocker

32 (29.35%)

Multivitamins

23 (21.10%)

Angiotensin converting enzyme inhibitor

22 (20.18%)

Selective serotonin reuptake inhibitor

20 (18.34%)

Thyroid hormone

19 (17.43%)

Angiotensin receptor block

15 (13.76%)

Anticonvulsant

13 (11.92%)

**Table 2.** Investigatory Studies Ordered and Performed for Patients Admitted for Syncope and Its Results
	N = 109(%)
Orthostatic vital signs
Done	45 (41.28%)
Positive	23 (51.11%)
Not done	64 (58.71%)
Telemetry
Ordered	106 (97.24%)
Normal sinus rhythm	85 (80.18%)
Sinus bradycardia	14 (13.20%)
Bundle branch block	14 (13.20%)
First degree atrioventricular block	10 (9.43%)
Atrial fibrillation/flutter	7 (6.60%)
Premature atrial contraction	3 (2.83%)
Paced rhythm	3 (2.83%)
Nonsustained ventricular tachycardia	3 (2.83%)
Supraventricular tachycardia	1 (0.94%)
Sinus arrhythmia	1 (0.94%)
Sinus tachycardia	1 (0.94%)
Not ordered	3 (2.83%)
Electrocardiogram
Ordered	106 (97.24%)
Normal sinus rhythm	73 (68.86%)
Sinus bradycardia	13 (12.26%)
Right bundle branch block	13 (12.26%)
Nonspecific ST wave changes	10 (9.43%)
Left ventricular hypertrophy	10 (9.43%)
First degree atrioventricular block	8 (7.54%)
Premature atrial contraction	7 (6.60%)
Atrial fibrillation/flutter	7 (6.60%)
Sinus tachycardia	6 (5.66%)
Premature ventricular contraction	6 (5.66%)
Sinus arrhythmia	5 (4.71%)
Poor R wave progression	5 (4.71%)
Left bundle branch block	4 (3.77%)
Left anterior fascicular block	4 (3.77%)
Intraventricular conduction delay	4 (3.77%)
Lateral wall ischemia	3 (2.83%)
Left atrial enlargement	2 (1.88%)
Anterolateral wall ischemia	1 (0.94%)
Old inferior wall myocardial infarction	1 (0.94%)
Prolonged QT interval	1 (0.94%)
Not ordered	3 (2.83%)
Electroencephalogram
Ordered	49 (44.95%)
Negative	47(95.91%)
Positive	2 (4.08%)
Primary generalized epilepsy	1 (50%)
Left temporal region epilepsy	1 (50%)
Nuclear stress test
Ordered	4 (3.66%)
Positive	0 (0%)
Negative	4 (100%)
Tilt table test
Ordered	3 (2.75%)
Positive	1 (33.33%)
Negative	2 (66.66%)
Intracardiac loop recorder placement
Ordered	5(4.58%)
Pacemaker interrogation
Ordered	2 (1.83%)
Electrophysiological studies
Ordered	0 (0%)

Table 2. Investigatory Studies Ordered and Performed for Patients Admitted for Syncope and Its Results

N = 109(%)

Orthostatic vital signs

Done

45 (41.28%)

Positive

23 (51.11%)

Not done

64 (58.71%)

Telemetry

Ordered

106 (97.24%)

Normal sinus rhythm

85 (80.18%)

Sinus bradycardia

14 (13.20%)

Bundle branch block

14 (13.20%)

First degree atrioventricular block

10 (9.43%)

Atrial fibrillation/flutter

7 (6.60%)

Premature atrial contraction

3 (2.83%)

Paced rhythm

3 (2.83%)

Nonsustained ventricular tachycardia

3 (2.83%)

Supraventricular tachycardia

1 (0.94%)

Sinus arrhythmia

1 (0.94%)

Sinus tachycardia

1 (0.94%)

Not ordered

3 (2.83%)

Electrocardiogram

Ordered

106 (97.24%)

Normal sinus rhythm

73 (68.86%)

Sinus bradycardia

13 (12.26%)

Right bundle branch block

13 (12.26%)

Nonspecific ST wave changes

10 (9.43%)

Left ventricular hypertrophy

10 (9.43%)

First degree atrioventricular block

8 (7.54%)

Premature atrial contraction

7 (6.60%)

Atrial fibrillation/flutter

7 (6.60%)

Sinus tachycardia

6 (5.66%)

Premature ventricular contraction

6 (5.66%)

Sinus arrhythmia

5 (4.71%)

Poor R wave progression

5 (4.71%)

Left bundle branch block

4 (3.77%)

Left anterior fascicular block

4 (3.77%)

Intraventricular conduction delay

4 (3.77%)

Lateral wall ischemia

3 (2.83%)

Left atrial enlargement

2 (1.88%)

Anterolateral wall ischemia

1 (0.94%)

Old inferior wall myocardial infarction

1 (0.94%)

Prolonged QT interval

1 (0.94%)

Not ordered

3 (2.83%)

Electroencephalogram

Ordered

49 (44.95%)

Negative

47(95.91%)

Positive

2 (4.08%)

Primary generalized epilepsy

1 (50%)

Left temporal region epilepsy

1 (50%)

Nuclear stress test

Ordered

4 (3.66%)

Positive

0 (0%)

Negative

4 (100%)

Tilt table test

Ordered

3 (2.75%)

Positive

1 (33.33%)

Negative

2 (66.66%)

Intracardiac loop recorder placement

Ordered

5(4.58%)

Pacemaker interrogation

Ordered

2 (1.83%)

Electrophysiological studies

Ordered

0 (0%)

**Table 3.** Imaging Studies Ordered and Performed for Patients Admitted for Syncope and Its Results
	N = 109(%)
ICA: internal carotid artery.
Cranial computed tomography
Ordered	83 (76.14%)
Normal	56 (67.46%)
Microvascular disease	17 (20.48%)
Chronic basal ganglia infarct	5 (6.02%)
Hematoma	2 (2.40%)
Meningioma	2 (2.40%)
Chronic ischemic changes	1 (1.20%)
Central cortical atrophy	1 (1.20%)
Parenchymal volume loss	1 (1.20%)
Calcification	1 (1.20%)
Nonspecific white matter changes	1 (1.20%)
Small intraparenchymal hemorrhage	1 (1.20%)
Basal ganglia neuroepithelial cyst	1 (1.20%)
Cavernous malformation	1 (1.20%)
Hemorrhagic contusion	1 (1.20%)
Acute Maxillary sinusitis	1 (1.20%)
Not ordered	26 (23.85%)
Carotid ultrasound
Ordered	36 (33.02%)
Normal	31 (86.11%)
Proximal ICA bilateral stenosis (60-79%)	1 (2.77%)
Proximal ICA bilateral stenosis (40-59%)	1 (2.77%)
Right ICA stenosis (80-89%)	1 (2.77%)
Bilateral stenosis ICA (40-59%)	1 (2.77%)
Left ICA mild to moderate plaque	1 (2.77%)
Not ordered	73 (66.97%)
Echocardiogram
Ordered	76 (69.72%)
Diastolic dysfunction	37 (46.68%)
Concentric hypertrophy	27 (35.52%)
Normal	14 (18.42%)
Mild mitral regurgitation	12 (15.78%)
Mild tricuspid regurgitation	9 (11.84%)
Mitral annulus calcification	8 (10.52%)
Moderate to severe mitral regurgitation	8 (10.52%)
Mild Aortic regurgitation	5 (6.57%)
Moderate aortic regurgitation	5 (6.57%)
Moderate aortic stenosis	5 (6.57%)
Moderate tricuspid regurgitation	5 (6.57%)
Mild aortic stenosis	4 (5.26%)
Mild pulmonary hypertension	4 (5.26%)
Mild left ventricular hypertrophy	4 (5.26%)
Mild bilateral atrial enlargement	4 (5.26%)
Moderate pulmonary hypertension	2 (2.63%)
Severe right atrial enlargement	2 (2.63%)
Mild to moderate global hypokinesis	2 (2.63%)
Bioprosthetic valve	2 (2.63%)
Severe tricuspid regurgitation	1 (1.31%)
Speckled pattern	1 (1.31%)
Severe pulmonary hypertension	1 (1.31%)
Mild pericardial effusion	1 (1.31%)
Mild mitral stenosis	1 (1.31%)
Severe aortic stenosis	1 (1.31%)
Mild asymmetric hypertrophy	1 (1.31%)
Basal septum hypokinesis	1 (1.31%)
Mild aortic root dilation	1 (1.31%)
Mild basal septal hypertrophy	1 (1.31%)
Primum atrial septal defect	1 (1.31%)
Paramembranous ventricular septal defect	1 (1.31%)
Endocardial cushion defect	1 (1.31%)
Not ordered	33 (30.27%)

Table 3. Imaging Studies Ordered and Performed for Patients Admitted for Syncope and Its Results

N = 109(%)

ICA: internal carotid artery.

Cranial computed tomography

Ordered

83 (76.14%)

Normal

56 (67.46%)

Microvascular disease

17 (20.48%)

Chronic basal ganglia infarct

5 (6.02%)

Hematoma

2 (2.40%)

Meningioma

2 (2.40%)

Chronic ischemic changes

1 (1.20%)

Central cortical atrophy

1 (1.20%)

Parenchymal volume loss

1 (1.20%)

Calcification

1 (1.20%)

Nonspecific white matter changes

1 (1.20%)

Small intraparenchymal hemorrhage

1 (1.20%)

Basal ganglia neuroepithelial cyst

1 (1.20%)

Cavernous malformation

1 (1.20%)

Hemorrhagic contusion

1 (1.20%)

Acute Maxillary sinusitis

1 (1.20%)

Not ordered

26 (23.85%)

Carotid ultrasound

Ordered

36 (33.02%)

Normal

31 (86.11%)

Proximal ICA bilateral stenosis (60-79%)

1 (2.77%)

Proximal ICA bilateral stenosis (40-59%)

1 (2.77%)

Right ICA stenosis (80-89%)

1 (2.77%)

Bilateral stenosis ICA (40-59%)

1 (2.77%)

Left ICA mild to moderate plaque

1 (2.77%)

Not ordered

73 (66.97%)

Echocardiogram

Ordered

76 (69.72%)

Diastolic dysfunction

37 (46.68%)

Concentric hypertrophy

27 (35.52%)

Normal

14 (18.42%)

Mild mitral regurgitation

12 (15.78%)

Mild tricuspid regurgitation

9 (11.84%)

Mitral annulus calcification

8 (10.52%)

Moderate to severe mitral regurgitation

8 (10.52%)

Mild Aortic regurgitation

5 (6.57%)

Moderate aortic regurgitation

5 (6.57%)

Moderate aortic stenosis

5 (6.57%)

Moderate tricuspid regurgitation

5 (6.57%)

Mild aortic stenosis

4 (5.26%)

Mild pulmonary hypertension

4 (5.26%)

Mild left ventricular hypertrophy

4 (5.26%)

Mild bilateral atrial enlargement

4 (5.26%)

Moderate pulmonary hypertension

2 (2.63%)

Severe right atrial enlargement

2 (2.63%)

Mild to moderate global hypokinesis

2 (2.63%)

Bioprosthetic valve

2 (2.63%)

Severe tricuspid regurgitation

1 (1.31%)

Speckled pattern

1 (1.31%)

Severe pulmonary hypertension

1 (1.31%)

Mild pericardial effusion

1 (1.31%)

Mild mitral stenosis

1 (1.31%)

Severe aortic stenosis

1 (1.31%)

Mild asymmetric hypertrophy

1 (1.31%)

Basal septum hypokinesis

1 (1.31%)

Mild aortic root dilation

1 (1.31%)

Mild basal septal hypertrophy

1 (1.31%)

Primum atrial septal defect

1 (1.31%)

Paramembranous ventricular septal defect

1 (1.31%)

Endocardial cushion defect

1 (1.31%)

Not ordered

33 (30.27%)

**Table 4.** Number of Imaging Test Ordered for Patients Admitted for Syncope and Its Impact on the Hospital Length of Stay
	N (%)	Length of stay in days
No imaging test ordered	9 (8.25%)	2.22
One imaging test ordered	27 (24.77%)	2.44
Two imaging tests ordered	46 (42.20%)	2.58
Three imaging tests ordered	27 (24.77%)	3.07

Table 4. Number of Imaging Test Ordered for Patients Admitted for Syncope and Its Impact on the Hospital Length of Stay

N (%)

Length of stay in days

No imaging test ordered

9 (8.25%)

2.22

One imaging test ordered

27 (24.77%)

2.44

Two imaging tests ordered

46 (42.20%)

2.58

Three imaging tests ordered

27 (24.77%)

3.07

**Table 5.** Number of Imaging Test Ordered (Echocardiogram, Carotid Ultrasound, and Cranial Computed Tomography) and Its Association to Patient’s Hospital Length of Stay
Hospital length of stay	0 test (N = 9)	1 test (N = 27)	2 tests (N = 46)	3 tests (N = 27)	P (ANOVA)	P (KW)
Mean ± SD	2.222 ± 1.481	2.444 ± 1.396	2.587 ± 1.627	3.074 ± 1.639	0.368
Median(minimum - maximum)	1 (1 - 4)	2 (1 - 7)	2 (1 - 6)	3 (1 - 7)		0.352

Table 5. Number of Imaging Test Ordered (Echocardiogram, Carotid Ultrasound, and Cranial Computed Tomography) and Its Association to Patient’s Hospital Length of Stay

Hospital length of stay

0 test (N = 9)

1 test (N = 27)

2 tests (N = 46)

3 tests (N = 27)

P (ANOVA)

P (KW)

Mean ± SD

2.222 ± 1.481

2.444 ± 1.396

2.587 ± 1.627

3.074 ± 1.639

0.368

Median(minimum - maximum)

1 (1 - 4)

2 (1 - 7)

2 (1 - 6)

3 (1 - 7)

0.352

**Table 6.** Number of Imaging Test Ordered (Echocardiogram, Carotid Ultrasound, and Cranial Computed Tomography) and Its Influence on Admitting Diagnosis
Number of imaging test ordered	Syncope	Vasovagal syncope	Syncope vs. seizure	Total
Chi-square P value = 0.4165, nominal logistic regression P value = 0.939.
0	7 (8.092)	1 (0.330)	1 (0.578)	9
1	22 (24.275)	2 (0.991)	3 (1.734)	27
2	43 (41.358)	1 (1.688)	2 (2.954)	46
3	26 (24.275)	0 (0.991)	1 (1.734)	27
Total	98	4	7	109

Table 6. Number of Imaging Test Ordered (Echocardiogram, Carotid Ultrasound, and Cranial Computed Tomography) and Its Influence on Admitting Diagnosis

Number of imaging test ordered

Syncope

Vasovagal syncope

Syncope vs. seizure

Total

Chi-square P value = 0.4165, nominal logistic regression P value = 0.939.

7 (8.092)

1 (0.330)

1 (0.578)

22 (24.275)

2 (0.991)

3 (1.734)

43 (41.358)

1 (1.688)

2 (2.954)

26 (24.275)

0 (0.991)

1 (1.734)

Total

109

**Table 7.** Number of Imaging Test Ordered (Echocardiogram, Carotid Ultrasound, and Cranial Computed Tomography) and Its Influence on Discharge Diagnosis
Number of imaging test ordered	Syncope	Vasovagal syncope	Neurocardiogenic syncope	Syncope with seizure	Syncope vs. seizure	Total
Chi-square P value = 0.1507; nominal logistic regression P value = 0.782.
0	8 (8.2569)	0 (0.3303)	0 (0.1651)	0 (0.1651)	1 (0.0826)	9
1	23 (24.770)	2 (0.9908)	1 (0.4954)	1 (0.4954)	0(0.2477)	27
2	43 (42.2018)	2 (1.6881)	0 (0.8440)	1 (0.8440)	0 (0.4220)	46
3	26 (24.7706)	0 (0.9908)	1 (0.4954)	0 (0.4954)	0 (0.2477)	27
Total	100	4	2	2	1	109

Table 7. Number of Imaging Test Ordered (Echocardiogram, Carotid Ultrasound, and Cranial Computed Tomography) and Its Influence on Discharge Diagnosis

Number of imaging test ordered

Syncope

Vasovagal syncope

Neurocardiogenic syncope

Syncope with seizure

Syncope vs. seizure

Total

Chi-square P value = 0.1507; nominal logistic regression P value = 0.782.

8 (8.2569)

0 (0.3303)

0 (0.1651)

1 (0.0826)

23 (24.770)

2 (0.9908)

1 (0.4954)

0(0.2477)

43 (42.2018)

2 (1.6881)

0 (0.8440)

1 (0.8440)

0 (0.4220)

26 (24.7706)

0 (0.9908)

1 (0.4954)

0 (0.4954)

0 (0.2477)

Total

100

109

**Table 8.** Admitting and Discharge Diagnosis of Patients Admitted for Syncope
	N = 109 (%)
Admitting diagnosis
Syncope	98 (89.90%)
Syncope with fall	7 (6.42%)
Syncope vs. Seizure	4 (3.66%)
Discharge diagnosis
Syncope	100 (91.74%)
Vasovagal syncope	4 (3.66%)
Neurocardiogenic syncope	2 (1.83%)
Syncope with seizure	2 (1.83%)
Syncope vs. Seizure	1 (0.91%)

Table 8. Admitting and Discharge Diagnosis of Patients Admitted for Syncope

N = 109 (%)

Admitting diagnosis

Syncope

98 (89.90%)

Syncope with fall

7 (6.42%)

Syncope vs. Seizure

4 (3.66%)

Discharge diagnosis

Syncope

100 (91.74%)

Vasovagal syncope

4 (3.66%)

Neurocardiogenic syncope

2 (1.83%)

Syncope with seizure

2 (1.83%)

Syncope vs. Seizure

1 (0.91%)