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Great English is a must!! No grammar errors!) (Article Attached) (Read the full request) (3 Pages, Double Spaced, APA Format) -------------------------------- Subject of the paper: This is a non research appraisal. It should contain all the infos below. Article name: Waytz, J., Cifu, S. A, & Stern, D. C. Scott (2018). Evaluation and management of patients with syncope. JAMA, 319(21), 2227-2228. Requirement: Using selected reading above Introduction Article topic/focus Author(s) Aim of assignment Critique of Article The article critique should be a methodological review specific to type of article (for example, qualitative or quantitative) . The analysis must be three pages. The content of the review should also include: Ethical review Analysis of findings Limitations Discussion Application (translation) to practice specialty Future implications Other information: APA Format, three pages. Format: APA FormatNo plagiarism is accepted *** The work will be checked for plagiarism through Turnitin by the professor. It is essential for everything to be free of plagiarism otherwise sanctions will be imposed*** -------- Thank you for your support syncope_article.pdf Unformatted Attachment Preview Clinical Review & Education JAMA Clinical Guidelines Synopsis Evaluation and Management of Patients With Syncope Josh Waytz, MD; Adam S. Cifu, MD; Scott D. C. Stern, MD GUIDELINE TITLE 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope RELEASE DATE March 9, 2017 DEVELOPERS American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) FUNDING SOURCES ACC and AHA TARGET POPULATION Adult and pediatric patients with suspected syncope (this synopsis focuses on adult patients) MAJOR RECOMMENDATIONS AND RATINGS • Take a detailed history and perform a physical examination in all patients with syncope (strength of recommendation, I; level of evidence, B-NR [based on nonrandomized trials]). Summary of the Clinical Problem Syncope, defined as a transient loss of consciousness due to global cerebral hypoperfusion, is a common symptom encountered in clinical practice that currently accounts for 0.8\% to 2.4\% of all ED visits.1 The prognosis of syncope varies according to etiology, with 1-year mortality estimates ranging from 0\% among patients with vasovagal syncope to 30\% in patients with cardiac syncope.2 Characteristics of the Guideline Source The guideline was developed by the ACC, AHA, and HRS without commercial support.1 The ACC/AHA Task Force on Clinical Practice Guidelines selected experts, mostly in the fields of cardiology, electrophysiology, and emergency medicine, to form a writing committee. The literature review was conducted from July to October 2015 and included syncope guidelines published by other organizations and societies. The task force implemented a policy to ensure author relationships with industry were appropriately disclosed (Table). Evidence Base The guideline makes a strong recommendation that a detailed history taking and physical examination be performed in all patients. The authors cite multiple studies that identify historical and physical examination features that portend a worse prognosis. These include absence of prodrome, exertional syncope, abnormal vital signs, and history of heart disease. The authors also cite evidence that an attending physician can make a diagnosis using only the history, physical examination, and ECG results in 63\% of patients with a diagnostic accuracy of 88\%.3 The guideline also recommends a 12-lead ECG be performed in all patients with syncope, citing evidence that the presence of atrial fibrillation, left ventricular hyperjama.com • A resting 12-lead electrocardiogram (ECG) is useful in the initial evaluation of patients with syncope (strength of recommendation, I; level of evidence, B-NR). • Hospital evaluation and treatment are recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope (strength of recommendation, I; level of evidence, B-NR). • Patients with presumed reflex-mediated syncope (which includes vasovagal, carotid sinus sensitivity, and situational syncope) can be managed in the outpatient setting (strength of recommendation, IIa; level of evidence, C-LD [based on limited data]). • In intermediate-risk patients with an unclear cause, a structured emergency department (ED) observation protocol can be effective in reducing hospital admission (strength of recommendation, IIa; level of evidence, B-R [based on randomized trial data]). trophy, intraventricular conduction disturbances, and ventricular pacing were independently associated with an increase in all-cause 1-year mortality.4 The 3 final recommendations included in this synopsis pertain to patients at high, low, and intermediate risk of poor outcomes such as myocardial infarction, readmission, and death. The guideline recommends that high-risk patients, those with serious medical conditions including certain arrhythmias such as sustained ventricular tachycardia, symptomatic supraventricular tachycardia, or thirddegree heart block; acute heart failure; certain structural abnormalities such as severe aortic stenosis or hypertrophic cardiomyopathy; or noncardiac conditions such as severe gastrointestinal bleeding or major traumatic injury, should be admitted to the hospital. Conversely, the guideline suggests that low-risk patients with clear reflex-mediated syncope can be managed in the outpatient setting. Vasovagal syncope has been shown to carry no increased risk Table. Guideline Rating Standard Rating Establishing transparency Good Management of conflict of interest in the guideline development group Good Guideline development group composition Good Clinical practice guideline–systematic review intersection Fair Establishing evidence foundations and rating strength for each of the guideline recommendations Good Articulation of recommendations Good External review Fair Updating Good Implementation issues Good (Reprinted) JAMA June 5, 2018 Volume 319, Number 21 © 2018 American Medical Association. All rights reserved. Downloaded From: by a Kaohsiung Med Univ User on 08/17/2018 2227 Clinical Review & Education JAMA Clinical Guidelines Synopsis of mortality in patients followed up for a mean of 8.6 years,5 whereas cardiac syncope as well as syncope of unknown cause were associated with an increased risk of mortality. Patients with syncope are considered at intermediate risk if they have certain characteristics such as age 50 years or older, history of cardiac disease, cardiac device without evidence of dysfunction, concerning ECG findings such as bundle-branch block or Q waves (without acute changes), family history of sudden cardiac death, or symptoms not consistent with reflex-mediated syncope. The guideline suggests that use of a structured ED observation protocol/unit—which often includes accelerated testing (ie, telemetry, hourly vital signs, tilt-table testing)—and enhanced multidisciplinary involvement safely reduce admissions in this group. Benefits or Harms The benefit of robust, evidence-based triage of patients with syncope is that those at highest risk of serious outcomes receive the necessary evaluation and treatment without excessive utilization of resources in patients who have a benign cause. Potential harm lies in the weakness of some of the data, such as the unproven safety of the above-mentioned syncope units. Because the ability to risk stratify patients is imperfect, it is possible that the adoption of the guideline will not lead to expected benefit and may lead to increased costs through excessive evaluation or actual harm to patients. Discussion The recommendation for the use of a structured ED observation protocol/unit for the management of patients with intermediate-risk syncope is not well founded on data. Although studies supporting this recommendation show fewer hospital admissions with use of “syncope units,” the safety of these protocols is unproven. One Areas in Need of Future Study There is strong consensus on how to approach the management of patients presenting with syncope, but there are few high-quality trial data to support this consensus. This is especially true for patients at intermediate risk of adverse outcomes. Trials that enroll a welldefined group of intermediate-risk patients, randomize them to management in an observation unit that could be widely replicated or to standard of care, and consider both clinical and utilization outcomes would be welcome. Related guidelines and other resources 2010 ACCF/AHA Assessment of Cardiovascular Risk in Asymptomatic Adults http://www.onlinejacc.org/content/56/25/e50 2009 European Society of Cardiology Guidelines for the Diagnosis and Management of Syncope https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines /Syncope-Guidelines-on-Diagnosis-and-Management-of Author Affiliations: Pritzker School of Medicine, University of Chicago, Chicago, Illinois (Waytz); University of Chicago, Chicago, Illinois (Cifu, Stern). the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017;136(5):e60-e122. Corresponding Author: Adam S. Cifu, MD, Section of General Internal Medicine, University of Chicago, 5841 S Maryland Ave, MC 3051, Chicago, IL 60637 (adamcifu@uchicago.edu). 2. Yasa E, Ricci F, Magnusson M, et al. Cardiovascular risk after hospitalisation for unexplained syncope and orthostatic hypotension. Heart. 2018;104(6):487-493. Section Editor: Edward H. Livingston, MD, Deputy Editor, JAMA. 3. van Dijk N, Boer KR, Colman N, et al. High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment Study. J Cardiovasc Electrophysiol. 2008;19(1):48-55. ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of 2228 of the trials cited was underpowered and used an electrophysiology consult team to supervise discharge for these patients, an aspect of the trial unlikely to be scalable.6 The second trial is not generalizable because 47\% of 633 “high-risk” patients were excluded on the basis of physician judgment alone.7 D-dimer testing to evaluate patients for the diagnosis of pulmonary embolism might prove a useful adjunct in the workup of unexplained syncope. In a recent study, 4.2\% of 560 patients with unexplained syncope and without clinical signs of deep vein thrombosis, tachypnea, tachycardia, or hypotension had pulmonary emboli.8 4. Pérez-Rodon J, Martínez-Alday J, Barón-Esquivias G, et al. Prognostic value of the electrocardiogram in patients with syncope: data from the Group for Syncope Study in the Emergency Room (GESINUR). Heart Rhythm. 2014; 11(11):2035-2044. 5. Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347(12):878-885. 6. Shen WK, Decker WW, Smars PA, et al. Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management. Circulation. 2004;110(24):3636-3645. 7. Sun BC, McCreath H, Liang LJ, et al. Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission. Ann Emerg Med. 2014;64(2): 167-175. 8. Prandoni P, Lensing AW, Prins MH, et al; PESIT Investigators. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med. 2016;375(16):1524-1531. JAMA June 5, 2018 Volume 319, Number 21 (Reprinted) © 2018 American Medical Association. All rights reserved. Downloaded From: by a Kaohsiung Med Univ User on 08/17/2018 jama.com ... Purchase answer to see full attachment