• Monica Solbiati, Franca Dipaola, Paolo Villa, Sonia Seghezzi, Ivo Casagranda, Filippo Rabajoli, Elisa Fiorini, Lorenzo Porta, Giovanni Casazza, Antonio Voza, Franca Barbic, Nicola Montano, Raffaello Furlan, and Giorgio Costantino.
• Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Pronto Soccorso e Medicina d'Urgenza, Milano.
• Acad Emerg Med. 2020 Jan 1; 27 (1): 15-23.

BackgroundArrhythmia is one of the most worrisome causes of syncope. Electrocardiographic (ECG) monitoring is crucial for the management of non-low-risk patients in the emergency department (ED). However, its diagnostic accuracy and optimal duration are unknown. We aimed to assess the diagnostic accuracy of ECG monitoring in non-low-risk patients with syncope in the ED.MethodsThis prospective multicenter observational study included adult patients presenting to the ED after syncope. Patients without an obvious etiology after ED evaluation who were classified by ED physicians as being at non-low risk of adverse events underwent ECG monitoring. We assessed sensitivity, specificity, and diagnostic yield (defined as the proportion of patients with true-positive ECG monitoring findings) of ECG monitoring in the identification of 7- and 30-day adverse and arrhythmic events according to monitoring duration.ResultsOf 242 patients included in the study, 29 patients had 7-day serious outcomes. Ten additional patients had serious outcomes at 30 days. The overall sensitivity, specificity, and diagnostic yield of ECG monitoring in the identification of 7-day adverse events were 0.55 (95% confidence interval [CI] = 0.36 to 0.74], 0.93 (95% CI = 0.89 to 0.96), and 0.07 (95% CI = 0.04 to 0.10), respectively. The sensitivity, specificity, and diagnostic yield of >12-hour ECG monitoring in the identification of 7-day adverse events were 0.89 (95% CI = 0.65 to 0.99), 0.78 (95% CI = 0.67 to 0.87), and 0.18 (95% CI = 0.12 to 0.28), respectively. Similar results were observed for 30-day adverse events. The median (interquartile range) ECG monitoring time was 6.5 (6 to 15) hours. ECG monitoring findings were positive in 31 patients.ConclusionsAlthough the overall diagnostic accuracy of ECG monitoring is fair, its sensitivity at >12 hours' duration is substantially higher. These results suggest that prolonged (>12 hours) monitoring is a safe alternative to hospital admission in the management of non-low-risk patients with syncope in the ED.© 2019 by the Society for Academic Emergency Medicine.

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