University of Groningen Patterns of orthostatic hypotension and the evaluation of syncope van Wijnen, Veera Kariina

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Patterns of orthostatic hypotension and the evaluation of syncope

van Wijnen, Veera Kariina

DOI:

10.33612/diss.112725119

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van Wijnen, V. K. (2020). Patterns of orthostatic hypotension and the evaluation of syncope. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.112725119

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CHAPTER

10

FOLLOW-UP OF SYNCOPE PATIENTS FROM THE

EMERGENCY DEPARTMENT IN A SYNCOPE UNIT: WHO

MIGHT BENEFIT?

Veera K. van Wijnen, Reinold O.B. Gans, Wouter Wieling, Jan C. ter Maaten, Mark P.M. Harms

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ABSTRACT

Objectives To identify (pre) syncope patients that might benefit from follow-up in a syncope unit based on patient-reported outcome measures after initial evaluation at the emergency department.

Design Prospective cohort study

Setting and Participants Consecutive suspected (pre)syncope patients (≥18 years) referred to the emergency department were included. Patients with an identified serious cause of (pre) syncope were excluded. After the initial evaluation at the emergency department all patients received an invitation to the syncope unit for evaluation and management.

Methods At the syncope unit patients received a standardized evaluation and subsequent investigations if indicated. Management was according guidelines and outcomes were quality of life and recurrences after one year of follow-up.

Results One hundred and one (pre)syncope patients were included, however 22% did not visit the syncope unit. Of the 72 patients visiting the syncope unit (median age 63 (27) years, 68% male), 68% of patients showed an improvement during follow-up with a reduction of (pre)syncope recurrences, while 31% had the same number or more recurrences of (pre)syncope. Improvement was associated with a younger age and was more difficult to achieve in patients with orthostatic hypotension. Quality of life improved in 80% of patients with a history of recurrent syncope. Conclusions and Implications Follow-up at the syncope unit seems beneficial for younger patients and patients with recurrent syncope, resulting in a reduction of recurrences and improved quality of life. Older patients showed no clear improvement in patient-reported outcome measures, suggesting multiple factors involved. A randomized controlled trial is needed to determine which patients benefit from referral to a syncope unit.

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INTRODUCTION

The optimal follow-up of patients with suspected syncope at the emergency department (ED) is still unknown. The 2018 European Society of Cardiology (ESC) syncope guideline indicates that implementation of novel care pathways, such as referral to a syncope unit, is indicated in (pre) syncope patients with high risk characteristics (opposed to admission), intermediate risk patients (e.g. older patients with orthostatic hypotension) and patients with recurrent (reflex) syncope (1). A syncope unit is a facility featuring a standardized approach to the diagnosis and management of transient loss of consciousness (1,2) and is therefore thought to ensure better management of syncope patients. It may offer an alternative to admission, especially in intermediate risk patients and in low risk patients with recurrent syncope.

Several studies have shown that a syncope unit improves diagnostic rate, reduces diagnostic testing and improves therapeutic management of patients with syncope (2-6). Data on the effect of a syncope unit on patient-reported outcome measures are limited, even though reduction of syncope and syncope-associated admission is a quality indicator of a syncope unit (2). One study has investigated this, showing that a syncope unit at the ED vs. routine care did not result in a decrease of syncopal recurrences during two years of follow-up, despite better diagnostic rate (4). The effect on quality of life has been studied in one study, which showed no differences between patients following routine care and patients admitted to an observational unit (5).

The aim of this study was to study which patients referred to the syncope unit might benefit from follow-up using patient-reported outcome measures (7,8). Consecutive (pre) syncope patients in the ED, without an identified serious underlying condition, were referred to the syncope unit. Patient-reported outcome measurements were recurrences of (pre)syncope and Quality of Life (QoL).

METHODS

Patients

All consecutive patients with suspected syncope referred to the ED during office hours between December 2015 and February 2017 were included in a prospective cohort study in a tertiary teaching hospital. Exclusion criteria: Age <18 years, hemodynamic instability, in need of immediate investigations/treatment (such as an emergent computed tomography angiogram to exclude dissection or pulmonary embolism), psychologically-, physically- or cognitively unfit, unable to attend follow-up visits in the syncope unit, unwilling or unable to give informed consent, transient loss of consciousness not fitting the definition of suspected syncope (described below) or a life expectancy of less than one year. The study was approved by the Medical Ethical Committee (METc 2015/209) and all patients gave written informed consent. The trail was registered in the Netherlands Trial Register (NTR5651).

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Syncope

Syncope was defined as a transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration and spontaneous complete recovery (1). Severe presyncope was defined as the feeling of almost losing consciousness with similar prodromal symptoms as in syncope. Patients with severe presyncope are as likely as patients with syncope to experience critical interventions or adverse events like bradydysrhytmia and hemorrhage. Furthermore, management of syncope and presyncope after ED admission is similar (1,9).

Study flow

All suspected (pre)syncope patients in the ED were seen by the residents of the specialties of emergency medicine, internal medicine or cardiology (Figure 1). After the initial assessment a research physician approached the patient for informed consent. Independent of the management of the attending physician, all patients received an invitation to the syncope unit. The first visit to the syncope unit was planned in the first month after ED presentation. The subsequent visits were planned after 2 months, 6 months and 12 months. All patients were requested to visit the syncope unit four times.

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Syncope unit

The syncope unit is part of the outpatient department of internal medicine and is a tertiary referral center for unexplained syncope. The unit has close collaboration with the department of cardiology and neurology. During the first visit to the syncope unit an extensive history was taken and physical examination performed, including orthostatic blood pressure measurement with continuous noninvasive finger arterial blood pressure measurement (10). Additional investigations were performed if indicated. The principal goals of the syncope unit were to determine the cause of the (pre) syncopal episode in order to prevent syncope recurrences, limit physical injuries, improve QoL and prolong survival (1). In subjects with (suspected) cardiac syncope, the cardiologist decided upon the diagnostic and therapeutic path. In subjects with (suspected) reflex syncope, therapy consisted of education regarding awareness and possible avoidance of triggers, early recognition of prodromal symptoms and performing counter pressure manoeuvres to abort the episode (1,11). In patients with orthostatic hypotension, the underlying cause was investigated. Education regarding orthostatic blood pressure regulation and orthostatic hypotension was given (12). In drug-induced orthostatic hypotension the offending agent was reduced, if possible. Expansion of extracellular fluid volume was the main goal in patients with orthostatic hypotension with suspected autonomic dysfunction. In absence of supine hypertension, patients were advised to take 2-3L of fluids a day and 12 gram of sodium chloride. Same applied to (mainly) young subjects with reflex syncope. Other advices, like sleeping with the head elevated, using compression stocking, avoiding day time naps and large meals, were given. If these advices were not enough fludrocortisone or midodrine was considered. In subjects with initial orthostatic hypotension counter pressure manoeuvres were trained (13). In patients with suspected psychogenic pseudo syncope, explanation was given and referral to a psychologist was advised.

Outcome measures

Syncope and pre-syncope recurrence

Episodes of (pre)syncope in the previous year until the ED visit were compared with recurrences in the follow-up year. Patients were categorized as improved if there were no recurrences of (pre) syncope or if there was a decrease in (pre)syncopal episodes compared to the previous year. Quality of Life

Quality of Life was assessed with the SF-12 health survey. Patients were asked to fill out the SF-12 health survey before the first visit to the syncope unit and after 12 months of follow-up. If patients did not attend follow-up visits, QOL at 12 months was assessed via telephone or by mail. The SF-12 health survey consists of 12 items and scores the generic QoL. It is used to calculate two components: the physical component summary scale (PCS) and the mental component summary scale (MCS). Both scales have a relatively high reliability and validity (14). All raw scores from PCS and MCS were converted linearly to a scale ranging from 0 to 100, with zero indicating the worst QoL and 100 the best QoL. Improvement of MCS and PCS was defined when the MCS or PCS score was at least one point higher, respectively.

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Statistical analysis

IBM SPSS statistics 22 (SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) was used for statistical analysis. Demographic and clinical data was expressed as proportion for categorical data and mean with standard deviation or median with interquartile ranges, where appropriate. Between group differences in unpaired continuous data were analyzed with the Mann-Whitney U test or Kruskal Wallis if applicable, while binary data were analyzed with the Chi-Squared test. To analyze QoL, all scores were calculated by multiplying the different responses with weight for that score (15). PCS and MCS at baseline were compared with PCS and MCS after one year with Wilcoxon signed rank test and between different groups with Mann-Whitney U test.

RESULTS

Patient characteristics

Two hundred eighteen suspected syncope and severe presyncope patients were screened for eligibility to participate. Thirty-eight patients did not want to participate and another 79 patients met one of the exclusion criteria (of which 22 had a serious condition that needed immediate assessment and/or treatment). One hundred and one (pre)syncope patients were included, however 22% did not visit the syncope unit. The reasons consisted of no longer needing a physician’s consultation (n=10) or a comorbidity with a higher priority (n= 7, i.e. cardiac comorbidity, memory loss, illness of spouse, fracture and unexpected death (due to pancreatitis)). Patient characteristics of the 72 included patients are shown in Table 1. Management at the ED by the attending physician consisted of admission in 19% of these patients. All-cause mortality after a year was 5.1%. No adverse events occurred within the first 30 days and the causes of death were related to pre-existing co morbidities.

Before the first visit to the syncope unit, 100% of patients had an electrocardiogram, 27.8% an ecg-holter, 22.8% an exercise test, 27.8% a cardiac ultrasound, 19.0% a cerebral - computed tomography, 7.6% a magnetic resonance imaging of the head, 10.1% an electroenphalography and 6.3% had autonomic function tests. These tests had been done in the weeks to years before the first visit to the syncope unit, initiated by other physicians.

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Table 1. Demographic and clinical characteristics of 79 patients referred to the syncope unit

Age, years, median (IQR) 63 (27)

Sex, male, n (%) 54 (68.4)

Cardiovascular comorbidities, n (%) 45 (57.0)

Hypertension 34 (43.0)

Myocardial infarction 11 (13.9)

Heart Failure 3 (3.8)

Heart rhythm disorders 13 (16.5)

Pacemaker/ICD 3 (3.8)

Peripheral vascular disease 7 (8.9)

Thrombosis 8 (10.1)

Parkinson’s disease 3 (3.8)

Diabetes Mellitus 9 (11.4)

Antihypertensive medication 37 (46.8)

B-blocker 20 (25.3)

ACE-inhibitor or Angiotensin blocker 26 (32.9)

Calcium antagonist 8 (10.1) Diuretics 19 (24.1) ≥2 antihypertensive drugs 26 (32.9) Antidepressants 7 (8.9) Polypharmacy (>5) 30 (38.0) Admission, n (%) 15 (19.0)

Days until first SU visit, median (IQR) 25 (19)

Additional tests performed in follow-up year

by SU and other specialists, n (%)

No additional tests 44 (55.7)

Autonomic function test 25 (31.6)

Electrocardiogram 13 (16.5)

Holter 7 (8.9)

Cardiac ultrasound 6 (7.6)

Ergometry 3 (3.8)

Reveal device 21 (1.3)

All-cause mortality within 1 year follow-up 4 (5.1)

ED = emergency department. ICD = implantable cardioverter defibrillator. SU = syncope unit.

Syncopal recurrences

Of the 54 (68%) patients that improved during the follow-up year compared to the previous year, 48 had no recurrences and six had fewer recurrences. Of the 25 patients who did not improve, 18 had the same number of recurrences and seven had more recurrences. Improvement was associated with a younger age and presenting to the ED with an episode of syncope rather than presyncope (Table 2).

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Table 2. Patient characteristics of patients who improved and did not improve regarding (pre) syncope recurrences Improved N = 54 No improvement N = 25 p-value Age, median, IQR 56 (28) 72 (21) <0.001* Sex, male 37 (68.5) 17 (68.0) 1.000

Syncope | Presyncopex _{44 | 10} _{13 | 12} _.009*

Diagnosis by expert reference standard

Vasovagal reflex syncope 35 (64.8) 11 (44.0) Na

Situational reflex syncope 4 (7.4) 1 (4.0) Na

Cardiac syncope 2 (3.7) - Na

Initial orthostatic hypotension 3 (5.5) 1 (4.0) Na

Orthostatic hypotension 5 (9.3) 7 (28.0) Na

Psychogenic pseudo syncope - 2 (8.0) Na

Unexplained syncope 3 (5.6) 1 (4.0) Na

Other cause of T-LOC 2 (3.7) 2 (8.0) Na

Total number of syncope during lifetime, median (IQR) 2.0 (4) 2.0 (6) .848

Total number of (pre)syncope previous year,

including ED presentation, n (%) .447

1 episode 37 (68.5) 20 (80.0)

2 episodes 8 (14.8) 2 (8.0)

3 or more episodes 9 (16.7) 3 (12.0)

Follow-up year (pre) syncope, n (%)

No recurrences 48 (88.9) - Na

1 recurrence 3 (5.6) 10 (40.0) Na

2 recurrences 2 (3.7) 5 (20.0) Na

3 or more recurrences 1 (1.9) 10 (40.0) Na

ED = emergency department. Na = not applicable, because the numbers are too small for statistical comparison (diagnosis categories), because the table is based on recurrences (follow-up). SU = syncope unit. T-LOC = transient loss of consciousness. X:57 patients were referred to the syncope unit because of syncope, 22 because of severe pre-syncope. *P<0.05 was considered significant.

Quality of Life

Changes in QoL were assessed in patients who attended the first visit to the syncope unit and returned the SF-12 health survey after one year of follow-up (n=70). The 51% of patients who improved in mental health (MCS) had a significant lower median score at baseline (47.7 (IQR 9.6)) than patients who did not improve (55.2 (IQR 10.9) p=0.001). The 43% of patients who improved in physical health (PCS) also had a significantly lower median score at baseline (41.2 (IQR 15.9) vs. 52.1 (IQR 16.5) p= 0.000). Improvement in PCS was related to a lifelong history of more frequent syncope episodes (4.5 (IQR 6.0) vs. 2.0 (IQR 2.0). Furthermore, 80% of patients with recurrent (pre) syncopal episodes in the year up to ED presentation showed improvement in QoL. Patients who did not improve in PCS (57%) had significantly more often orthostatic hypotension as the cause of (pre)syncope. QoL changes on an individual level are shown in the Appendix.

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DISCUSSION

According the ESC guideline of syncope management referral to the syncope unit after initial presentation at the ED is indicated in a subcategory of (pre)syncope patients. This study suggests that based on patient-reported outcome measures, referral of younger syncope patients with a history of recurrent (reflex)syncope is beneficial. The number of patients in the other subcategories (e.g. orthostatic hypotension, cardiac syncope) were too small to conclude who might benefit from referral.

Recurrent (pre)syncope

In general, most patients improved during follow-up, compared to the previous year. Only seven patients deteriorated during follow-up. A younger age was associated with a decrease in syncope recurrences. Furthermore, data of this study suggest that patients with reflexsyncope benefit from referral to a syncope unit. These findings are in line with our expectations, as multiple studies have shown that education and training of physical counter pressure manoeuvres are very effective in the prevention of reflex syncope (11,16,17). However, not all patients with reflex syncope improved in our study. In addition, no association was found between a history of recurrent syncope and improvement during follow-up, even though patients with recurrent syncope are the category to be referred to the syncope unit (1,18). Both findings are likely explained by the heterogeneity of our population i.e. wide range in age (older patients are less likely to experience prodromal symptoms), co morbidities and different causes of (pre)syncope. A reduction of (pre)syncope recurrences is an important clinical outcome measure (see QoL below), but it is important to realize that this most likely to be achieved in (young) patients with reflex syncope.

Quality of Life

Patients with a lifelong history of syncope and patients with recurrent syncope in the year prior to ED presentation improved in QoL. This is consistent with a study in patients with recurrent reflex syncope between the age of 18 and 70 years (18). In this study non-pharmacological treatment resulted in improvement of QoL and a decrease in recurrences, with improvement in QoL being greatest in patients with a greater reduction in syncope burden. Our findings indicate that referral of patients with recurrent syncope may have a positive effect on QoL.

In our study 51% of the patients improved in QoL’s MCS during follow-up while 43% improved in the PCS. In both groups, improvement was related to a significant lower score at baseline and patients who did not improve had a median baseline score that was already within the ranges of normal values (19), i.e. regression to the mean.

Despite improvement in QoL, the median PCS in all patients after one year of follow-up was still lower than average population values (19). This is in accordance to previous studies, showing that the morbidity of recurrent syncope is equivalent to chronic conditions such as severe rheumatoid arthritis and low back pain (20). In addition, in the analysis of QoL it needs to be considered that QoL improves considerably over time. Moreover, an older age, recurrences, higher level of

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morbidity and a psychogenic diagnosis are predictive of a worse QoL (20-22). QoL is an important patient-reported outcome measure, but susceptible for many confounders. For future studies, the syncope QoL scale might be more specific (23).

Older adults

The assessment of a syncope episode in an older patient is challenging because it can be attributed to multiple factors. Older patients are more likely to have more than one possible attributable diagnosis, polypharmacy, cardiovascular and cerebrovascular morbidity, amnesia for loss of consciousness, lack of witness accounts, falls and coexistent cognitive impairment (24,25). Therefore, it is assumed that a standardized approach in a syncope unit is of added value. However, in our study there was no clear improvement visible in the older population, and therefore QoL and recurrences may not be the best outcome measure. Previous studies have used reduction of unexplained syncope and reduction of admission as primary outcome measures (2). In geriatric patients, especially when syncope is combined with episodes of (unexplained) falling and multiple factors are thought to be involved, referral for a comprehensive geriatric assessment is indicated (25,26).

Orthostatic hypotension

Earlier studies have shown that the morbidity of orthostatic hypotension is substantial and the cause of orthostatic hypotension should be assessed to determine treatment and follow-up (10,12,27). This study confirms that the related morbidity of orthostatic hypotension is substantial, as only 5/12 patients improved in patient-reported outcomes. Whether follow-up of these patients at a syncope unit is beneficial could not be concluded by our results.

Strengths and Limitations

This study was the first to study patient selection and the utility of a syncope unit, after initial referral to the ED, in relation to patient-reported outcome measures in a heterogeneous population of (pre)syncope patients. The results give insight into patient categories who may benefit, as well as the challenges in using these outcome measures. This study has several limitations. First it was a single centre study in a tertiary referral hospital. Therefore results cannot be extrapolated to primary and secondary care. Secondly, the effect size of the management at the syncope unit could not be determined due to the absence of a control group. Thirdly, the main outcome measure compared recurrences in the previous year to recurrences in the follow-up year, which to a certain extent is susceptible to recall bias. By regular follow-up visits and careful history taking we aimed to limit this bias. We recommend that in future studies a larger group of heterogeneous (pre)syncope patients will be included in order to make clear recommendations.

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CONCLUSIONS AND IMPLICATIONS

Follow-up at the syncope unit after initial evaluation at the emergency department is potentially beneficial for younger patients and patients with recurrent syncope, since these patients improved in patient-reported outcomes, such as quality of life and decrease in recurrences. In older patients referral to the syncope unit in combination with a comprehensive geriatric assessment may be more beneficial, due to several attributable factors for (pre)syncope present in this age group. A randomized controlled trial is needed to determine which patients benefit from referral to a syncope unit.

Conflicts of interest

No conflicts of interest.

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Supplementary Table 1. Characteristics of patients who improved and patients who did not improved in

Mental Component Summary Scale

MCS improved

N = 36 MCS not improvedN = 34 Age, mean ±SD 59.9 ±18.1 56.5 ±19.8 .499

Sex, male 26 (72.2) 21 (61.8) .447

Syncope I near syncope 26 I 10 27 I 7 .582

Cardiovascular disease 23 (63.9) 15 (44.1) .149

Medication

Antihypertensive use 20 (55.6) 12 (35.3) 1.000

Antidepressant 1 (2.8) 5 (14.7) .102

Polypharmacy (>5) 15 (41.7) 8 (23.5) .131

Working diagnosis at the syncope unit by expert reference standard

Vasovagal reflex syncope 25 (69.4) 19 (55.9) .323

Situational reflex syncope 1 (2.8) 3 (8.8) .350

Cardiac syncope 2 (5.6) - .493

Initial orthostatic hypotension 2 (5.6) 2 (5.9) 1.000

Orthostatic hypotension 3 (8.3) 4 (11.8) .706

Psychogenic pseudo syncope - 2 (5.9) .232

Unexplained syncope 1 (2.8) 2 (5.9) .609

Other cause of T-LOC* 2 (5.6) 2 (5.9) 1.000

Risk stratification, n (%)

Low risk 13 (36.1) 23 (67.6) .010*

Intermediate risk 6 (16.7) 2 (5.9) .261

High risk 17 (47.2) 9 (26.5) .088

Admission 6 (16.7) 8 (23.5) .557

Total syncope (life), median (IQR) 2.0 (3.0) 3.0 (7.0) .085

Total (pre)syncope previous year,

including ED presentation, n (%)

1 episode 27 (75.0) 19 (55.9) .131

2 episodes 3 (8.3) 6 (17.6) .300

3 or more episodes 6 (16.7) 9 (26.5) .389

Follow-up year (pre) syncope, n (%)

No episodes 27 (75.0) 20 (58.8) .204

1 episode 5 (13.9) 5 (14.7) 1.000

2 episodes 2 (5.6) 4 (11.8) .422

3 or more 2 (5.6) 5 (14.7) .253

A decrease in (pre)syncopal episodes, n (%) 29 (80.6) 23 (67.6) .278

MCS score visit 1, median IQR 47.7 (9.6) 55.2 (10.9) .001* MCS score visit 4, median IQR 54.8 (6.7) 51.2 (16.5) .017* Delta change MCS, median IQR +7.1 (6.3) -3.9 (6.6) Na

PCS score visit 1, median IQR 48.7 (16.5) 42.7 (20.8) .264

PCS score visit 4, median IQR 48.4 (19.0) 49.6 (20.2) .920

Frequency of visits to syncope unit .052

One visit 7 (19.4) 3 (8.8)

Two visits 11 (30.6) 4 (11.8)

Three visits 3 (8.3) 6 (17.6)

Four visits 15 (41.7) 21 (61.8)

ED = emergency department. MCS = Mental Component Summary Scale. Na = not applicable. PCS = Physical Component Summary Scale. *= p<0.05 is statistically significant.

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Supplementary Table 2. Characteristics of patients who improved and patients who did not improved in

Physical Component Summary Scale

PCS improved

N = 30 PCS not improvedN = 40 Age, mean ±SD 54.4 ±20.8 61.1 ±17.0 .161

Sex, male 19 (63.3) 28 (70.0) .631

Syncope I near syncope 24 I 6 29 I 11 .578

Cardiovascular disease 14 (46.7) 24 (60.0) .335

Medication

Antihypertensive use 14 (46.7) 18 (45.0) 1.000

Antidepressant 4 (13.3) 2 (5.0) .391

Polypharmacy (>5) 12 (40.0) 11 (27.5) .331

Working diagnosis at the syncope unit by expert reference standard

Vasovagal reflex syncope 18 (60.0) 26 (65.0) .083

Situational reflex syncope 2 (6.7) 2 (5.0) 1.000

Cardiac syncope 1 (3.3) 1 (2.5) 1.000

Initial orthostatic hypotension 3 (10.0) 1 (2.5) .307

Orthostatic hypotension - 7 (17.5) .017*

Psychogenic pseudo syncope 2 (6.7) - .180

Unexplained syncope 3 (10.0) - .074

Other cause of T-LOC* 1 (3.3) 3 (7.5) .630

Risk stratification, n (%)

Low risk 18 (60.0) 18 (45.0) .237

Intermediate risk 1 (3.3) 7 (17.5) .126

High risk 11 (36.7) 15 (37.5) 1.000

Admission 7 (23.3) 7 (17.5) .562

Total syncope (life), median (IQR) 4.5 (6.0) 2.0 (2.0) .005* Total (pre)syncope previous year,

including ED presentation, n (%)

1 episode 16 (53.3) 30 (75.0) .077

2 episodes 2 (6.7) 7 (17.5) .283

3 or more episodes 12 (26.7) 3 (5.0) .002*

Follow-up year (pre) syncope, n (%)

No episodes 18 (60.0) 29 (72.5) .311

1 episode 5 (16.7) 5 (12.5) .735

2 episodes 3 (10.0) 3 (5.0) 1.000

3 or more 4 (13.3) 3 (2.5) .452

A decrease in (pre)syncopal episodes, n (%) 23 (76.7) 29 (72.5) .786

PCS score visit 1, median IQR 41.2 (15.9) 52.1 (16.5) .000* PCS score visit 4, median IQR 50.9 (18.3) 45.6 (21.0) .114

Delta change PCS, median IQR +6.2 (7.8) -3.7 (6.4) na

MCS score visit 1, median IQR 51.8 (10.6) 48.8 (14.6) .380

MCS score visit 4, median IQR 53.1 (7.9) 52.4 (10.9) .803

Frequency of visits to syncope unit .821

One visit 5 (16.7) 5 (12.5)

Two visits 5 (16.7) 10 (25.0)

Three visits 5 (16.7) 4 (10.0)

Four visits 15 (50.0) 21 (52.5)

ED = emergency department. MCS = Mental Component Summary Scale. Na = not applicable. PCS = Physical Component Summary Scale. *= p<0.05 is statistically significant.

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Supplementary Figure 1. Individual tracings and median score in QoL changes during one year of

follow-up at the syncope unit. The panels above show (pre)syncope patients who improved in mental health score (left, n = 36) and who did not improve (left, n = 34). The panels below shows patients who improved in physical health score (left, n = 30) and did not improve (right, n = 40). Red thick line represents the median change. The dotted lines represent the mean and standard deviation of average population scores. ED = emergency department.

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