Lewis R P, Boudoulas H, Voto S, Schaal S F, Stang J M
Trans Am Clin Climatol Assoc. 1985;96:131-40.
The two new methods for defining arrhythmic syncope described in this report represent important additions to the traditional syncope workup. Both techniques uncovered a substantial number of arrhythmic causes of syncope which had not been found by standard techniques. A major strength of each method is that symptoms can be directly related to the arrhythmia. The 68% incidence of diagnostic EPS abnormalities which we found was identical to the study of DiMarco but higher than reported by others (which have ranged from 12 to 48%) (18, 20, 21). More critical patient selection and more comprehensive study techniques most likely account for these differences. It is our opinion that a significant number of patients whose diagnosis was "syncope of undetermined etiology" in previous studies did indeed have an arrhythmic basis for their symptoms which was not identified. At this point the issue of "cost effectiveness" inevitably arises. Do all patients with syncope in whom a cause is not initially apparent (i.e., up to 50% of such patients) require either TTEM or EPS? The answer is obviously no, not for this whole population. However, the evident power of TTEM and EPS requires that the question should be raised. Furthermore, the results of the invasive EPS study strongly suggest that mortality and morbidity can be reduced. Table 11 shows the relative costs for all of the diagnostic tests for arrhythmic syncope. From this it can be seen that TTEM is quite inexpensive and therefore very cost-effective. It is an ideal adjunct to 24 hour ambulatory monitoring in selected patients. Although invasive EPS studies are costly, it is not difficult to incur equal costs by use of several days of prolonged monitoring, especially if done in the hospital. Thus, in identified patients with abnormal but "not diagnostic" ambulatory monitoring studies, patients with abrupt syncope, patients with frequent symptoms or patients with known underlying heart disease, further evaluation with TTEM or EPS should be strongly considered.
本报告中描述的两种用于定义心律失常性晕厥的新方法是对传统晕厥检查的重要补充。这两种技术都发现了大量标准技术未发现的心律失常性晕厥病因。每种方法的一个主要优点是症状可直接与心律失常相关。我们发现诊断性电生理检查异常的发生率为68%，与迪马尔科的研究相同，但高于其他研究报告的发生率（其他研究报告的发生率在12%至48%之间）（18、20、21）。更严格的患者选择和更全面的研究技术很可能是造成这些差异的原因。我们认为，在先前的研究中诊断为“病因不明的晕厥”的大量患者，其症状确实有心律失常的基础，但未被识别出来。此时，“成本效益”问题不可避免地出现了。对于所有最初病因不明显的晕厥患者（即这类患者中高达50%的患者），都需要进行倾斜试验或电生理检查吗？答案显然是否定的，并非针对所有这类患者。然而，倾斜试验和电生理检查的显著作用要求提出这个问题。此外，侵入性电生理检查研究的结果强烈表明，死亡率和发病率可以降低。表11显示了心律失常性晕厥所有诊断检查的相对成本。由此可见，倾斜试验成本相当低，因此性价比很高。它是对选定患者进行24小时动态监测的理想辅助手段。虽然侵入性电生理检查研究成本很高，但通过几天的延长监测也不难产生同等成本，尤其是在医院进行监测时。因此，对于已确定的动态监测研究异常但“未确诊”的患者、突发晕厥的患者、症状频繁的患者或已知有潜在心脏病的患者，应强烈考虑用倾斜试验或电生理检查进行进一步评估。
