Boston Syncope Rule, 2007 (short-term risk)

Derivation: a priori

Validation: 362 ED patients with syncope

Signs of volume depletion

Persistent abnormal vital signs in the ED

Signs and symptoms of acute coronary syndrome

Signs of conduction disease

Worrisome cardiac history

Family history of sudden death

Primary central nervous system event

Valvular heart disease (from history or physical examination)

Critical intervention or adverse outcome at 30 days

Consider admission for one or more variables

Internal: 97% sensitivity, 62% specificity

External: none

25 variables in eight categories make it less practical

Canadian Syncope Risk Rule, 2016 (short-term risk)

Derivation: 4,030 ED patients with syncope

Validation: pending

Predisposition to vasovagal syncope (prodrome/trigger)

History of heart disease

Systolic blood pressure < 90 mm Hg or > 180 mm Hg

Elevated troponin level

Abnormal QRS axis (< 30 or > 110 degrees)

QRS duration > 130 milliseconds

Corrected QT interval > 480 milliseconds

ED diagnosis of vasovagal syncope

ED diagnosis of cardiac syncope

Serious event at 30 days: death, arrhythmia, MI, PE, aortic dissection, CVA, or procedural intervention for syncope

Estimated risk of serious adverse event at 30 days

Pending

Largest prospective study, outcomes consistent with guidelines, clarifies abnormal ECG findings, pending validation to support use of rule

EGSYS score, 2008 (short- and long-term risk)

Derivation: 260 ED patients with syncope

Validation: 258 ED patients with syncope

Palpitations preceding syncope (4 points)

Abnormal ECG findings* or history of heart disease (3 points)

Syncope during effort (3 points) or when supine (2 points)

Autonomic prodromes (−1 point)

Precipitating and/or predisposing factors (−1 point)

Probability of cardiogenic syncope at two years

Consider admission for score of 3 or higher

Internal: 92% sensitivity, 69% specificity

External: 56% sensitivity, 84% specificity

Mortality at two years was 2% in patients with scores < 3 and 21% for scores = 3

OESIL risk score, 2003 (long-term risk)

Derivation: 270 ED patients with syncope

Validation: 328 ED patients with syncope

Abnormal ECG findings*

Absence of prodromal syndrome

Age > 65 years

History of cardiac disease

Mortality at one year

Consider admission for one or more variables

Internal: 100% sensitivity, 22% specificity

External: 95% sensitivity, 31% specificity

Positive variables:

0: 0% mortality

1: 0.6% mortality

2: 14% mortality

3: 29% mortality

4: 53% mortality

ROSE study, 2010 (short-term risk)

Derivation: 550 ED patients with syncope

Validation: 550 ED patients with syncope

Anemia (hemoglobin = 9 g per dL [90 g per L])

Bradycardia (< 50 beats per minute)

Brain natriuretic peptide = 300 pg per mL (300 ng per L)

Chest pain with syncope

ECG showing Q waves (except in lead III)

Oxygen saturation < 94% on room air

Rectal examination showing occult blood (if gastrointestinal bleeding suspected)

Serious events at one month: death, acute MI, PE, CVA, arrhythmias, hemorrhage requiring transfusion of two or more units, subarachnoid hemorrhage, acute procedure, need for pacemaker in first month

Consider admission for one or more variables

Internal: 87% sensitivity, 66% specificity

One-year outcomes: 72% sensitivity, 71% specificity

External: none

Not useful for predicting outcomes at one year; first study to use a biomarker in risk stratification

San Francisco Syncope Rule, 2004 (short-term risk)

Derivation: 684 ED patients with syncope or near syncope

Validation: 791 ED patients with syncope or near syncope

Abnormal ECG findings*

Congestive heart failure

Hematocrit < 30%

Shortness of breath

Systolic blood pressure < 90 mm Hg

Serious events at seven days: acute MI, PE, CVA, arrhythmias, subarachnoid hemorrhage, return ED visit, readmission

Consider admission for one or more variables

Internal: 98% sensitivity, 56% specificity

External: 87% sensitivity, 52% specificity

First tool for short-term events (seven days); inconsistencies in validation scores, but the most studied decision tool