Original contributionPredicting Adverse Outcomes in Syncope
Introduction
Syncope is a common presentation to the Emergency Department (ED), however, a universally applied approach to appropriate management and criteria for hospitalization is lacking. Syncope accounts for approximately 1–3% of all ED visits and up to 6% of all hospital admissions nationwide (1, 2). The cost of care per hospital admission has been estimated at roughly $5300 per stay, for a total cost of over $2 billion per year nationally (1, 2, 3, 4, 5, 6, 7).
The ED workup of syncope centers on several goals. First, the Emergency Physician (EP) must identify those patients with life-threatening causes requiring immediate treatment. Second, the EP must identify those who would benefit from specific treatment or intervention. Third, the EP must identify those who remain without a diagnosis, despite appropriate workup, and who will require further evaluation. Central to this final goal is the determination of the appropriate setting for such evaluation, inpatient vs. outpatient (6). Despite these clear objectives, the ED evaluation of syncope is challenging. The differential diagnosis of syncope ranges from benign to immediately life-threatening conditions. Patients presenting to the ED with a complaint of syncope are often asymptomatic and well-appearing on arrival. Despite thorough evaluation, a cause is not established in 38–47% of cases (1, 7, 8). This presents a challenge to EPs as syncope patients are at risk for significant dysrhythmia and sudden death and could be among the well-appearing group (9). This concern is the impetus behind a great deal of research to assist the EP in identifying those patients at risk for cardiac mortality and significant dysrhythmia; and, ultimately deciding who should be admitted to the hospital for further evaluation and who is safe for discharge. Recommendations for hospital admission should be based on the potential for adverse outcomes if further evaluation and workup is delayed (10).
We, therefore, developed a clinical decision rule with the intent of validating it as the basis for this study (Table 1). This rule was designed by using criteria extracted primarily from the American College of Emergency Physicians’ (ACEP) clinical policy and recommendations of the San Francisco Syncope Rule as well as the clinical acumen of a group of expert emergency physicians, cardiologists, electrophysiologists, and internists (12, 13, 14). The objective of this study was to determine if our decision rule could accurately discriminate patients with syncope likely to have a critical intervention or adverse outcome. Ultimately, our goal is to enable the emergency practitioner to better discriminate syncope patients who require hospitalization from those who may be safely discharged home from the ED. We hope to ensure that no patient with a possible life-threatening etiology of syncope is discharged home, and at the same time institute a more judicious approach in deciding which patients require hospital admission for syncope.
Section snippets
Study Design and Setting
We conducted a prospective, observational, cohort study of consecutive patients presenting with syncope 24 h a day, 7 days a week between September 2003 and April 2004. All patients presented to the ED of a large urban teaching hospital with an annual ED census of 48,000 visits. Institutional review board (IRB) approval was received before initiation of the study.
Syncope was defined as a sudden and transient (< 5 min) loss of consciousness, producing a brief period of unresponsiveness and a
Results
There were 384 patients who had syncope and met inclusion criteria, 362 (94%) of whom were included in the study. There were 293/362 (81%) patients who completed their 30-day follow-up and were included in the analysis. Of patients lost to 30-day follow-up, admission rates and rates of adverse outcomes in the ED and during hospitalization were similar to those of patients who remained in the study. A total of 201/293 (69%) patients were admitted, with 56 outcomes occurring during
Discussion
This study suggests that the Boston Syncope Rule may be helpful in accurately identifying ED patients at risk for adverse outcomes. Utilizing our risk factors to screen syncope patients yielded a sensitivity of 97%, specificity of 62%, with a negative predictive value of 99%. In this population, admitting only those patients identified by the decision rule admissions would have led to a 48% reduction in hospital admissions. Clearly, in an overburdened health care system, the ability to safely
Limitations
There are a number of limitations of this study, including use of a single testing site, small sample size, and lack of long-term follow-up. The 19% of patients who were lost to 30-day follow-up may have caused us to underestimate the true number of adverse events and critical outcomes. If this were the case, then our estimates of the accuracy and safety of our rule may be overestimated. A total of 25 risk factors are a large number to remember, however, they can be shortened to the eight
Conclusion
In summary, despite careful history and physical examination, the EP can be assisted in discerning both etiology and, more importantly, outcome in syncope. Our syncope pathway may be useful in guiding the EP by helping to identify which patients are likely to have adverse outcomes or the need for critical interventions. Ultimately, this rule may significantly reduce hospital admissions and serve as a vehicle to contain both rising medical costs and adverse outcomes associated with unnecessary
References (24)
- et al.
Direct medical costs of syncope-related hospitalizations in the United States
Am J Cardiol
(2005) - et al.
Evaluation and outcome of emergency room patients with transient loss of consciousness
Am J Med
(1982) - et al.
Risk stratification of patients with syncope
Ann Emerg Med
(1997) - et al.
Is syncope a risk factor for poor outcomes?Comparison of patients with and without syncope
Am J Med
(1996) - et al.
Impact of the application of the American College of Emergency Physicians recommendations for the admission of patients with syncope on a retrospectively studied population presenting to the emergency department
Am Heart J
(2005) - et al.
Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes
Ann Emerg Med
(2004) - et al.
Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes
Ann Emerg Med
(2006) Syncope in the emergency departmentA cardiologist’s perspective
Emerg Med Clin North Am
(1995)- et al.
Establishing an approach to syncope in the emergency department
J Emerg Med
(1997) Evaluation and outcome of patients with syncope
Medicine
(1990)
Beth Israel Deaconess Medical Center Institutional Review
The costs of recurrent syncope of unknown origin in elderly patients
Pacing Clin Electrophysiol
Cited by (132)
Diagnostic approaches to syncope in Internal Medicine Departments and their effect on mortality
2022, European Journal of Internal MedicineRisk stratification of syncope: Current syncope guidelines and beyond
2022, Autonomic Neuroscience: Basic and ClinicalCan I Send This Syncope Patient Home From the Emergency Department?
2021, Journal of Emergency MedicineCanadian Cardiovascular Society Clinical Practice Update on the Assessment and Management of Syncope
2020, Canadian Journal of CardiologyA Population-Based Study Evaluating Sex Differences in Patients Presenting to Emergency Departments With Syncope
2020, JACC: Clinical ElectrophysiologyCitation Excerpt :Prognostic scores used to risk stratify syncope patients in the ED have not been widely adopted, however; there are risk factors that have consistently been identified as predictors of adverse outcomes. These include older age (>60 years) (19–21), male sex (21–25), and severe structural or coronary heart disease (heart failure, low left ventricular ejection fraction, or previous myocardial infarction) (10,19,21,24–33). A higher prevalence of these risk factors was found among admitted patients in a multicenter Italian study of patients presenting to the ED compared with risk factors in those who were discharged (27).
Risk Stratification of Older Adults Who Present to the Emergency Department With Syncope: The FAINT Score
2020, Annals of Emergency Medicine