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1 Department of Emergency Medicine
2 Gerontology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Address correspondence to Shamai A Grossman, MD, MS, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, WCC2, One Deaconess Road, Boston, MA 02115. E-mail: sgrossma{at}caregroup.harvard.edu
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Methods. To assess the impact of sex on the frequency of syncope and the rate of identifying a specific etiology among elderly patients who present to the emergency department (ED), a retrospective chart review was performed during a 1-year period. Consecutive patients older than 65 years presenting with syncope to a large urban teaching hospital were enrolled. Inclusion criterion was documented loss of consciousness with no other obvious etiology of loss of consciousness such as stroke or seizure. Charts were screened for presenting history, ethnicity, sex, comorbid conditions, living circumstances, outpatient medication, and cardiac risk factors and outcomes including acute coronary syndromes, myocardial infarction, and death.
Results. During 1 year of observation, 7496 women (60%) of 12,401 patients over the age of 65 presented to our ED, and 219 (2.9%) of these met inclusion criteria for syncope. In comparison, 4905 (40%) men presented to the ED, 104 (2.1%) of whom had syncope (relative risk of syncope for women vs men, 1.38; 95% confidence interval, 1.09–1.74). Men were more likely to have comorbid conditions including coronary artery disease (p 
.01), prior myocardial infarction (p .03), and diabetes mellitus (p .03) than were women. No sex differences were noted in living circumstances, such as living alone, with assistance, or in an institution. Forty-two percent of patients received no diagnosis on discharge from the hospital. Sixty-nine of 147 women admitted (47%) had no etiology of their syncope as compared to 27 (32%) of men. The relative risk for no diagnosis in women versus men was 1.67 (95% confidence interval, 1.07–2.61).
Conclusions. Considerable numbers of patients presenting to EDs with syncope remain without a diagnosis. Women, despite being less likely to have concomitant coronary artery disease or diabetes, are significantly more likely to present to an ED with syncope, yet less likely to be discharged with a defined etiology.
Sixty percent of patients do not have a readily diagnosed etiology of syncope based on initial ED history, physical examination, and electrocardiogram (EKG) (5). Current data suggest that at least 30%–50% of patients with syncope leave the hospital without a defined etiology of their syncopal event (6–8). Patients with syncope have a 1.3% higher risk of death than the general population (9).
It has been previously shown that there are significant sex differences in presentation, evaluation, and therapy in a number of conditions including coronary artery disease (CAD), stroke, and trauma (10–25) Cardiovascular disease is the leading cause of death and disability for women, as nearly 250,000 women die of myocardial infarction each year (10). Women with CAD present more frequently than men with atypical chest pain, nausea, and gastrointestinal symptoms and are less likely than men with similar symptoms to be admitted for evaluation or to receive thrombolytic therapy or revascularization procedures (11–20).
Sex-related differences in presentation and evaluation of CAD may reflect a more general difference in the presentation, medical evaluation, and management of men and women. These differences might be reflected in other conditions, such as syncope. Furthermore, one study (26) suggests that women may be more likely to have psychiatric diagnoses such as panic, generalized anxiety, somatization, and major depression when presenting with syncope. In contrast, men with syncope are more likely to have alcohol and drug disorders (26).
The need to better assess differences in presentation and treatment based on sex is critical in applying a properly tailored approach to medical care. Several factors have forced a reassessment of syncope patients including increasing emphasis on evidence-based medicine, efforts to reduce unnecessary and expensive medical testing, and concerns over the rapidly rising costs of medical care. The objective of this study is to assess sex-related differences in the presentation and evaluation of syncope among elderly patients who present to the ED.
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METHODS |
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We identified all patients age 65 and older during a 1-year period (July 1, 1998 to June 30, 1999) who presented to the ED with either a documented chief complaint of syncope, or were given an International Classification of Diseases, 9th Edition (ICD-9) code 780.2 (syncope and collapse) from the ED as either an admitting or discharge diagnosis. Syncopal events were reviewed if coded as either the primary or secondary diagnosis. Research assistants abstracted each computerized discharge summary and when needed, the paper medical record as well, to confirm that the patient truly had syncope. Abstractors were blinded to the study objective. To adjudicate uncertain cases, discrepancies between the ICD-9 diagnosis of syncope and chart documentation of the event (i.e., no documented loss of consciousness or stroke were noted) were then reviewed by the principal investigator.
Charts were screened for presenting history, ethnicity, sex, comorbid conditions, living circumstances, outpatient medication, and cardiac risk factors and outcomes including acute coronary syndromes, myocardial infarction, and death. Information was gathered and documented using standardized abstraction forms about the performance and outcome of diagnostic studies done in the ED and during hospitalization including EKGs and cardiac enzymes. Statistical analyses were performed using the chi-square test (or Fisher's exact test, when appropriate) and t test to compare binary and continuous responses, respectively. The 95% confidence intervals (CIs) were also constructed using asymptotic approximation. Return visits to the ED or hospitalization/rehospitalization within 72 hours of discharge were also identified.
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RESULTS |
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Six thousand twenty-eight patients were admitted during that same time period—2416 (40%) men and 3612 (60%) women. Of 323 patients with syncope presenting to the ED, 93 (29%) were felt to have a benign etiology of syncope and to be safe for discharge. Of the 219 women with syncope, 72 (33%) were discharged home from the ED compared to 21 (20%) men. Thus, women with syncope were 1.6 times as likely to be discharged home as were men. In turn, men with syncope were significantly more likely to be admitted than were women (Table 2).
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.01), prior myocardial infarction (p .03), congestive heart failure (p .01), and diabetes mellitus (p .03). No significant sex differences were found in living circumstances (including living alone, with assistance, or in an institution), ethnicity, or outpatient medications (with the exception of platelet inhibitors, which were more commonly used by women). Overall, 42% of patients received no specific diagnosis for their syncopal event on discharge from the hospital, and 50% of the 93 patients discharged from the ED did not have a specific diagnosis for their syncopal event. Eleven of 21 men (50%) and 36 of 72 women (50%) were discharged from the ED without a diagnosis (relative risk, 2.14; 95% CI, 1.09–4.20). In contrast, 69 of 147 admitted women (47%) had no etiology of their syncope on hospital discharge as compared to 27 (32%) of men (relative risk, 1.44; 95% CI, 1.01–2.06).
Four of 230 patients discharged from the hospital with syncope returned within 72 hours (3 women, 1 man). All of these patients were readmitted, one had a newly diagnosed stroke, and the others were diagnosed with syncope secondary to volume depletion and orthostasis. No patient discharged directly from the ED returned within 72 hours.
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DISCUSSION |
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Although considerable numbers of patients presenting to EDs with syncope remain without diagnosis (6), we found that women are even more likely than men to have no diagnosis established after hospitalization for syncope (relative risk, 1.44; 95% CI, 1.01–2.06). The evaluation in the hospital which included, when deemed appropriate, computed tomography (CT), magnetic resonance imaging (MRI), electroencephalogram (EEG), EKG, echocardiogram (ECHO), carotid ultrasound, cardiac enzymes, and tilt table testing, showed no significant sex-based differences. Thus, the healthier patient population of women who have fewer risk factors for fatal and nonfatal cardiovascular events is more likely to be discharged from the hospital without finding a cause. Whether this lack of diagnosis relates directly to their lower prevalence of underlying cardiac disease is unclear.
We also found that at least to 72-hour follow-up, there is no apparent sex difference in determining an etiology of syncope. However, as only four patients discharged from the hospital with syncope returned within 72 hours, this sample size may be too small to demonstrate significant differences.
Anson and colleagues (28) have shown that women may be more likely to perceive and report symptoms and to magnify symptom severity than are men, although it is not clear whether this applies to older women. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) includes syncope as a manifestation of somatization, generalized anxiety, and substance abuse disorder (29). Anxiety and panic disorders, as well as major depression, may cause syncope in all ages by predisposing patients to vasovagal or neurally mediated reactions (26). Psychiatric disorders are often diagnosed in patients with syncope. In particular, Kapoor and colleagues (26) demonstrated an incidence of psychiatric diagnoses of 22% in patients aged >65; they have also shown that psychiatric illnesses are more common in patients with syncope of unknown etiology. All of these factors should be explored as an explanation for the disproportionate presentation of elderly women with syncope to the ED. It is possible that in many elderly women with syncope, symptoms may be less likely related to organic disease or medications, but more likely due to nonorganic causes such as overriding psychosocial or socioeconomic difficulty. However, we did not abstract data on comorbid conditions such as anxiety and depression in this study.
Our study examined living circumstances (such as living alone or in an institution) and did not find a statistically significant difference between the sexes. Future studies must specifically address the role of socioeconomic and psychosocial factors and frequent visits to the ED in elderly women with syncope of unknown etiology.
Limitations of this study include its retrospective design, use of a single testing site, small sample size, and lack of long-term follow-up. Men had more comorbidities which may have biased the diagnosis. In addition, 72-hour follow-up was only at a single institution and thus may have failed to capture some of the adverse outcomes. Finally, this study gathered limited information concerning patient demographic and living circumstances, which are important covariates that may have influenced our findings.
To improve the quality of care for women presenting with syncope, clinicians need to pursue a broader differential in evaluation of such patients including sociodemographic and psychosocial contributors as well as organic causes.
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Received November 4, 2003
Accepted June 17, 2004
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