Table 1

Emergency department syncope studies
No Year Study Variables Scoring system Endpoints Results1 Strengths Weakness
1 1997 Martin et al. • Abnormal ECG 0 to 4 1-year arrhythmias or deaths 4.4% score 0 One of the earliest studies Only long-term outcomes
• History of ventricular arrhythmia (1 point for each item)
• History of CHF 57.6% score 3 or 4 Not validated
• Age >45 years
2 2002 OESIL • Abnormal ECG 0 to 4 1-year mortality 0% score 0 Externally validated for Only long-term outcomes
• History of cardiovascular disease (1 point for each item) 0.6% score
• Lack of prodrome 14% score 2 up to 6 month outcomes Modest performance for outcomes up to 6 months
• Age >65 years
29% score 3
53% score 4
3 2003 Sarasin et al. • Age >65 years 0 to 3 Arrhythmias in unexplained ED syncope 2% score 0 Studied arrhythmia risk in unexplained syncope Only inpatients
• History of CHF (1 point for each item) 17% score 1 Internal validation on historical cohort
Abnormal ECG 35% score 2
27% score 3
No external validation
4 2004 San Francisco Syncope Rule • Abnormal ECG No item = No risk 7-day serious events Sensitivity 98% First tool for short-term events Wide variations in performance
• History of CHF
• Shortness of breath
• Hematocrit < 30% ≥ 1 item = risk Specificity 56% Most widely validated ECG variable too broad
• Triage systolic BP <90 mmHg
Included soft outcomes2
5 2007 Boston Syncope Rule • Compilation of 25 plausible variables ≥ 1 item = risk 30-day serious events Sensitivity 97% A thorough list of variables No statistical methods
Specificity 62% Not practical
No external validation
6 2008 STePS • Abnormal ECG ≥ 1 item = risk 10-day and 1-year events Not Reported Addresses the role of admissions to hospital Readmission to hospital was an outcome
• Trauma
• No prodrome
• Male sex
Not validated
7 2008 EGSYS • Palpitations before syncope (+4) Addition of all items Cardiac syncope probability 2% score <3 First study to incorporate variables from history Not generalizable - Syncope expert always available
• Abnormal ECG and/or heart disease (+3)
• Syncope during effort (+3) 2-year total mortality 13% score 3
• Syncope while supine (+2) 33% score 4
77% score >4 Internal validation 92% sensitivity
2% score <3
21% score ≥3 No robust external validation
• Autonomic prodrome (−1)
8 2009 Sun et al. • Age >90 years (+1) Addition of all items 30-day events among older (≥ 60 years) syncope patients 2.5% score −1, 0 First study to risk stratify older patients Retrospective
• Male sex (+1)
• History of arrhythmia (+1) 6.3% score 1,2 Can be applied only to older patients
• Triage systolic BP >160 (+1) Large sample size
• Abnormal ECG (+1)
• Abnormal troponin I (+1) 20% score 3 to 6 Not validated
• Near-syncope (−1)
9 2010 ROSE • BNP level ≥300 pg/ml Presence of any item 1-month serious events Sensitivity 87% First study to evaluate the role of BNP in risk stratification Short-term events included stroke
• Bradycardia ≤50 in ED/pre-hospital
• Positive fecal occult blood on rectal Specificity 66%
• Anemia – Hemoglobin ≤ 90 g/L Requires BNP testing that is not widely available
• Chest pain with syncope
• Q wave on ECG (except in lead III)
• O2 saturation ≤ 94% on room air Less than ideal sensitivity

ECG = Electrocardiogram, CHF = Congestive Heart Failure, OESIL = Osservatorio Epidemiologico sulla Sincope nel Lazio, BP = Blood Pressure, STePS = Short-Term Prognosis of Syncope, EGSYS = Evaluation of Guidelines in Syncope Study, BNP = Brain type or B-type Natriuretic Peptide.

1Results of validation phase when available.

2Soft outcomes = Cortical stroke and hospitalization on return visit with no serious events.

All studies used standard statistical methods to develop the tool except the Boston Syncope Rule study.

Thiruganasambandamoorthy et al.

Thiruganasambandamoorthy et al. BMC Emergency Medicine 2014 14:8   doi:10.1186/1471-227X-14-8

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