Abstract
Syncope is a common clinical presentation defined as a transient loss of consciousness (TLOC) due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. Different clinical decision rules (CDRs) and risk stratification scores have been developed to predict short- and long-term risks for adverse outcomes after syncope. The central theme of these prediction systems is consistent with the ESC syncope guidelines. Initial assessment according to the ESC guideline is essential until an optimal and well-validated risk score is available. The focus should be accurate risk stratification to allow prevention of adverse outcomes and optimize the use of limited healthcare resources. In this review article, we summarize and critically appraise the evidence regarding the CDRs for patients presenting with syncope.
Keywords: Syncope, clinical decision rules, healthcare, transient loss of consciousness, electrocardiogram, cardiac syncope.
Graphical Abstract
[1]
Brignole M, Moya A, de Lange FJ, et al. ESC Scientific document group. 2018 ESC guidelines for the diagnosis and management of syn-cope. Eur Heart J 2018; 39(21): 1883-948.
[http://dx.doi.org/10.1093/eurheartj/ehy037] [PMID: 29562304]
[http://dx.doi.org/10.1093/eurheartj/ehy037] [PMID: 29562304]
[2]
Thiruganasambandamoorthy V, Stiell IG, Sivilotti MLA, et al. Predicting short-term risk of arrhythmia among patients with syncope: The Canadian syncope arrhythmia risk score. Acad Emerg Med 2017; 24(11): 1315-26.
[http://dx.doi.org/10.1111/acem.13275] [PMID: 28791782]
[http://dx.doi.org/10.1111/acem.13275] [PMID: 28791782]
[3]
Liang Y, Li X, Tse G, Li G, Liu W, Liu T. Diagnostic value of cardiac troponin I and N-terminal pro-B-type natriuretic peptide in cardiac syncope. Cur Res Physiol 2021; 4: 24-8.
[http://dx.doi.org/10.1016/j.crphys.2021.01.003] [PMID: 34746823]
[http://dx.doi.org/10.1016/j.crphys.2021.01.003] [PMID: 34746823]
[4]
Lee S, Zhou J, Li KHC, et al. Territory-wide cohort study of Brugada syndrome in Hong Kong: Predictors of long-term outcomes using random survival forests and non-negative matrix factorisation. Open Heart 2021; 8(1)e001505
[http://dx.doi.org/10.1136/openhrt-2020-001505] [PMID: 33547222]
[http://dx.doi.org/10.1136/openhrt-2020-001505] [PMID: 33547222]
[5]
Serrano LA, Hess EP, Bellolio MF, et al. Accuracy and quality of clinical decision rules for syncope in the emergency department: A sys-tematic review and meta-analysis. Ann Emerg Med 2010; 56(4): 362-373.e1.
[http://dx.doi.org/10.1016/j.annemergmed.2010.05.013] [PMID: 20868906]
[http://dx.doi.org/10.1016/j.annemergmed.2010.05.013] [PMID: 20868906]
[6]
Costantino G, Casazza G, Reed M, et al. Syncope risk stratification tools vs. clinical judgment: An individual patient data meta-analysis. Am J Med 2014; 127(11)1126.e13
[http://dx.doi.org/10.1016/j.amjmed.2014.05.022]
[http://dx.doi.org/10.1016/j.amjmed.2014.05.022]
[7]
D’Ascenzo F, Biondi-Zoccai G, Reed MJ, et al. Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the emergency department with syncope: An international meta-analysis. Int J Cardiol 2013; 167(1): 57-62.
[http://dx.doi.org/10.1016/j.ijcard.2011.11.083] [PMID: 22192287]
[http://dx.doi.org/10.1016/j.ijcard.2011.11.083] [PMID: 22192287]
[8]
Del Rosso A, Ungar A, Maggi R, et al. Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: The EGSYS score. Heart 2008; 94(12): 1620-6.
[http://dx.doi.org/10.1136/hrt.2008.143123] [PMID: 18519550]
[http://dx.doi.org/10.1136/hrt.2008.143123] [PMID: 18519550]
[9]
Kariman H, Harati S, Safari S, Baratloo A, Pishgahi M. Validation of EGSYS score in prediction of cardiogenic syncope. Emerg Med Int 2015; 2015515370
[http://dx.doi.org/10.1155/2015/515370] [PMID: 26649200]
[http://dx.doi.org/10.1155/2015/515370] [PMID: 26649200]
[10]
Martin TP, Hanusa BH, Kapoor WN. Risk stratification of patients with syncope. Ann Emerg Med 1997; 29(4): 459-66.
[http://dx.doi.org/10.1016/S0196-0644(97)70217-8] [PMID: 9095005]
[http://dx.doi.org/10.1016/S0196-0644(97)70217-8] [PMID: 9095005]
[11]
Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes. Ann Emerg Med 2004; 43(2): 224-32.
[http://dx.doi.org/10.1016/S0196-0644(03)00823-0] [PMID: 14747812]
[http://dx.doi.org/10.1016/S0196-0644(03)00823-0] [PMID: 14747812]
[12]
Quinn JV, Stiell IG, McDermott DA, Kohn MA, Wells GA. The San Francisco syncope rule vs physician judgment and decision making. Am J Emerg Med 2005; 23(6): 782-6.
[http://dx.doi.org/10.1016/j.ajem.2004.11.009] [PMID: 16182988]
[http://dx.doi.org/10.1016/j.ajem.2004.11.009] [PMID: 16182988]
[13]
Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco syncope rule to predict patients with serious outcomes. Ann Emerg Med 2006; 47(5): 448-54.
[http://dx.doi.org/10.1016/j.annemergmed.2005.11.019]
[http://dx.doi.org/10.1016/j.annemergmed.2005.11.019]
[14]
Cosgriff TM, Kelly AM, Kerr D. External validation of the San Francisco syncope rule in the Australian context. CJEM 2007; 9(3): 157-61.
[http://dx.doi.org/10.1017/S1481803500014986] [PMID: 17488574]
[http://dx.doi.org/10.1017/S1481803500014986] [PMID: 17488574]
[15]
Reed MJ, Newby DE, Coull AJ, Prescott RJ, Jacques KG, Gray AJ. The ROSE (risk stratification of syncope in the emergency department) study. J Am Coll Cardiol 2010; 55(8): 713-21.
[http://dx.doi.org/10.1016/j.jacc.2009.09.049] [PMID: 20170806]
[http://dx.doi.org/10.1016/j.jacc.2009.09.049] [PMID: 20170806]
[16]
Sun BC, Mangione CM, Merchant G, et al. External validation of the San Francisco syncope rule Ann Emerg Med 2007; 94(4): 420-7. .e1-427.e4
[http://dx.doi.org/10.1016/j.annemergmed.2006.11.012] [PMID: 17210201]
[http://dx.doi.org/10.1016/j.annemergmed.2006.11.012] [PMID: 17210201]
[17]
Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Failure to validate the San Francisco syncope rule in an independent emergency department population. Ann Emerg Med 2008; 52(2): 151-9.
[http://dx.doi.org/10.1016/j.annemergmed.2007.12.007] [PMID: 18282636]
[http://dx.doi.org/10.1016/j.annemergmed.2007.12.007] [PMID: 18282636]
[18]
Kayayurt K, Akoglu H, Limon O, et al. Comparison of existing syncope rules and newly proposed anatolian syncope rule to predict short-term serious outcomes after syncope in the Turkish population. Int J Emerg Med 2012; 5(17): 17.
[http://dx.doi.org/10.1186/1865-1380-5-17] [PMID: 22520447]
[http://dx.doi.org/10.1186/1865-1380-5-17] [PMID: 22520447]
[19]
Tan C, Sim TB, Thng SY. Validation of the San Francisco Syncope rule in two hospital emergency departments in an Asian population. Acad Emerg Med 2013; 20(5): 487-97.
[http://dx.doi.org/10.1111/acem.12130] [PMID: 23672363]
[http://dx.doi.org/10.1111/acem.12130] [PMID: 23672363]
[20]
Bozorgi A, Hosseini K, Jalali A, Tajdini M. A new feasible syncope risk score appropriate for emergency department: A prospective co-hort study. Crit Pathw Cardiol 2018; 17(3): 151-4.
[http://dx.doi.org/10.1097/HPC.0000000000000146] [PMID: 30044256]
[http://dx.doi.org/10.1097/HPC.0000000000000146] [PMID: 30044256]
[21]
Dipaola F, Costantino G, Perego F. San Francisco syncope rule, osservatorio epidemiologico sulla sincope nel lazio risk score, and clinical judgment in the assessment of short-term outcome of syncope. Am J Emerg Med 2010; 28(4): 432-9.
[http://dx.doi.org/10.1016/j.ajem.2008.12.039]
[http://dx.doi.org/10.1016/j.ajem.2008.12.039]
[22]
Parry SW. Current issues with prediction rules for syncope. CMAJ 2011; 183(15): 1694-5.
[http://dx.doi.org/10.1503/cmaj.111529] [PMID: 21948727]
[http://dx.doi.org/10.1503/cmaj.111529] [PMID: 21948727]
[23]
Saccilotto RT, Nickel CH, Bucher HC, Steyerberg EW, Bingisser R, Koller MT. San Francisco syncope rule to predict short-term serious outcomes: A systematic review. CMAJ 2011; 183(15): E1116-26.
[http://dx.doi.org/10.1503/cmaj.101326] [PMID: 21948723]
[http://dx.doi.org/10.1503/cmaj.101326] [PMID: 21948723]
[24]
Grossman SA, Fischer C, Lipsitz LA, et al. Predicting adverse outcomes in syncope. J Emerg Med 2007; 33(3): 233-9.
[http://dx.doi.org/10.1016/j.jemermed.2007.04.001] [PMID: 17976548]
[http://dx.doi.org/10.1016/j.jemermed.2007.04.001] [PMID: 17976548]
[25]
Gomes DG, Kus T, Sant’anna RT, de Lima GG, Essebag V, Leiria TL. Simple risk stratification score for prognosis of syncope. J Interv Card Electrophysiol 2016; 47(2): 153-61.
[http://dx.doi.org/10.1007/s10840-016-0165-y] [PMID: 27394159]
[http://dx.doi.org/10.1007/s10840-016-0165-y] [PMID: 27394159]
[26]
Grossman SA, Bar J, Fischer C, et al. Reducing admissions utilizing the Boston syncope criteria. J Emerg Med 2012; 42(3): 345-52.
[http://dx.doi.org/10.1016/j.jemermed.2011.01.021] [PMID: 21421292]
[http://dx.doi.org/10.1016/j.jemermed.2011.01.021] [PMID: 21421292]
[27]
Mechanic OJ, Pascheles CY, Lopez GJ, et al. Using the Boston syncope observation management pathway to reduce hospital admission and adverse outcomes. West J Emerg Med 2019; 20(2): 250-5.
[http://dx.doi.org/10.5811/westjem.2018.11.39657] [PMID: 30881544]
[http://dx.doi.org/10.5811/westjem.2018.11.39657] [PMID: 30881544]
[28]
Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian syncope risk score to predict serious adverse events after emergency department assessment of syncope. CMAJ 2016; 188(12): E289-98.
[http://dx.doi.org/10.1503/cmaj.151469] [PMID: 27378464]
[http://dx.doi.org/10.1503/cmaj.151469] [PMID: 27378464]
[29]
Thiruganasambandamoorthy V, Sivilotti MLA, Le Sage N, et al. Multicenter emergency department validation of the Canadian syncope risk score. JAMA Intern Med 2020; 180(5): 737-44.
[http://dx.doi.org/10.1001/jamainternmed.2020.0288] [PMID: 32202605]
[http://dx.doi.org/10.1001/jamainternmed.2020.0288] [PMID: 32202605]
[30]
Probst MA, Gibson T, Weiss RE, et al. Risk stratification of older adults who present to the emergency department with syncope: The faint score. Acad Emerg Med 2020; 75(2): 147-58.
[http://dx.doi.org/10.1016/j.annemergmed.2019.08.429] [PMID: 31668571]
[http://dx.doi.org/10.1016/j.annemergmed.2019.08.429] [PMID: 31668571]
[31]
Colivicchi F, Ammirati F, Melina D, Guido V, Imperoli G, Santini M. OESIL (Osservatorio epidemiologico sulla sincope nel lazio) study investigators. Development and prospective validation of a risk stratification system for patients with syncope in the emergency depart-ment: the OESIL risk score. Eur Heart J 2003; 24(9): 811-9.
[http://dx.doi.org/10.1016/S0195-668X(02)00827-8] [PMID: 12727148]
[http://dx.doi.org/10.1016/S0195-668X(02)00827-8] [PMID: 12727148]
[32]
Hing R, Harris R. Relative utility of serum troponin and the OESIL score in syncope. Emerg Med Australas 2005; 17(1): 31-8.
[http://dx.doi.org/10.1111/j.742-6731.2005.00678.x] [PMID: 15675902]
[http://dx.doi.org/10.1111/j.742-6731.2005.00678.x] [PMID: 15675902]
[33]
Mora Pabón G, Alvarado J, Rojano M, et al. Frequency of adverse events in the short and medium term in patients with syncope classified as high and low risk according to the OESIL score. Revista Colombiana de Cardiologia 2017; 24(3): 241-9.
[http://dx.doi.org/10.1016/j.rccar.2016.09.015]
[http://dx.doi.org/10.1016/j.rccar.2016.09.015]
[34]
Díaz-Tribaldos DC, Mora G, Olaya A, Marín J, Sierra Matamoros F. Determination of prognostic value of the OESIL risk score at 6 months in a Colombian cohort with syncope evaluated in the emergency department; first Latin American experience. Arch Cardiol Mex 2018; 88(3): 197-203.
[http://dx.doi.org/10.1016/j.acmx.2017.06.007] [PMID: 28716580]
[http://dx.doi.org/10.1016/j.acmx.2017.06.007] [PMID: 28716580]
[35]
Costantino G, Perego F, Dipaola F, et al. STePS Investigators. Short- and long-term prognosis of syncope, risk factors, and role of hospital admission: Results from the STePS (Short-Term Prognosis of Syncope) study. J Am Coll Cardiol 2008; 51(3): 276-83.
[http://dx.doi.org/10.1016/j.jacc.2007.08.059] [PMID: 18206736]
[http://dx.doi.org/10.1016/j.jacc.2007.08.059] [PMID: 18206736]
[36]
Ungar A, Del Rosso A, Giada F, et al. Evaluation of guidelines in syncope study 2 group. Early and late outcome of treated patients re-ferred for syncope to emergency department: The EGSYS 2 follow-up study. Eur Heart J 2010; 31(16): 2021-6.
[http://dx.doi.org/10.1093/eurheartj/ehq017] [PMID: 20167743]
[http://dx.doi.org/10.1093/eurheartj/ehq017] [PMID: 20167743]
[37]
Ruwald MH, Ruwald AC, Jons C, et al. Evaluation of the CHADS2 risk score on short- and long-term all-cause and cardiovascular mortal-ity after syncope. Clin Cardiol 2013; 36(5): 262-8.
[http://dx.doi.org/10.1002/clc.22102] [PMID: 23450502]
[http://dx.doi.org/10.1002/clc.22102] [PMID: 23450502]
[38]
Sun BC, Derose SF, Liang LJ, et al. Predictors of 30-day serious events in older patients with syncope. Ann Emerg Med 2009; 54(6): 769-78.
[http://dx.doi.org/10.1016/j.annemergmed.2009.07.027]
[http://dx.doi.org/10.1016/j.annemergmed.2009.07.027]
Article Metrics
17
1