Canadian Syncope Risk Score Rules Out Serious Causes of Syncope in the ED

By Will Boggs MD

March 25, 2020

NEW YORK (Reuters Health) - The Canadian Syncope Risk Score (CSRS) accurately rules out serious causes of syncope in the emergency department (ED), a prospective Canadian study found.

"Using the CSRS will standardize and expedite the emergency department disposition decision making," Dr. Venkatesh Thiruganasambandamoorthy from Ottawa Hospital Research Institute and Ottawa Hospital told Reuters Health by email. "Medium-risk patients can potentially be managed outside the hospital with prolonged outpatient cardiac rhythm monitoring."

The primary focus of the ED evaluation of syncope, which accounts for 1% of ED visits, is to identify serious underlying conditions that may have caused the syncope. About 1 in 10 patients will have a serious underlying condition identified within 30 days, and as many as 5% of these will be identified only after discharge.

Dr. Thiruganasambandamoorthy and colleagues at nine large Canadian EDs sought to validate the CSRS, which they previously derived, to determine its ability to predict 30-day serious outcomes not evident during the index ED evaluation.

Among the 3,819 patients in the study, 139 (3.6%) experienced 30-day serious outcomes, including 107 with arrhythmic outcomes, 9 who died from unknown causes, and 32 who experienced non-arrhythmic outcomes.

Only three of 1631 patients (0.3%) at very low risk and nine of 1254 patients (0.7%) at low risk by CSRS experienced 30-day serious outcomes, compared with 40 of 78 patients (51.3%) in the very-high-risk group, the researchers report in JAMA Internal Medicine.

None of the very-low-risk or low-risk patients died or experienced ventricular arrhythmia.

At a threshold score of -1, the CSRS identified patients at risk of serious outcomes with 97.8% sensitivity and 44.3% specificity.

"Patients who present after syncope to the emergency department should be carefully evaluated for serious underlying conditions described in our study as outcomes," Dr. Thiruganasambandamoorthy. "At the end of the initial evaluation, if no serious underlying conditions are identified, the CSRS can be used to prognosticate the risk of serious outcomes within 30 days after the emergency department visit and decide regarding disposition and the need for outpatient cardiac rhythm monitoring."

"The information regarding 30-day risk can also be used as an aid to discuss with patients to decide disposition decisions by a shared decision-making approach," he said.

"Based on the study results, we recommend that patients with very-low-risk and low-risk CSRS be discharged, patients at medium risk be involved in a shared decision approach regarding disposition, and patients at high risk be hospitalized for a short course," the authors note. "We believe that implementation of the CSRS will improve patient safety and reduce health care resource use."

A calculator for determining the CSRS is available online at https://www.mdcalc.com/canadian-syncope-risk-score.

SOURCE: https://bit.ly/2y3C0qy JAMA Internal Medicine, online March 23, 2020.

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