Clinical Pathways
Clinical Pathways
Not life-threatening
Not life-threatening

Not life-threatening

View The Full Pathway

Decision

Do history, physical examination, and ECG suggest a benign etiology such as neurally-mediated syncope, or is patient otherwise low risk?

Yes

  • Manage as outpatient (Class II)

No

  • Risk-stratify patients using clinical findings and consider using risk-stratification scores (Class II)
  • High- and intermediate-risk patients should be sent to ED for evaluation

Background

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Clinical Risk-Stratification Tools

There are numerous risk stratification tools for syncopal patients, many of which have limited value in the UC setting. These risk-stratification tools should be applied only to patients for whom no apparent cause of syncope has been determined after the history, physical examination, and ECG interpretation. See Table 7, for a comparison of features of several risk-stratification tools, which are summarized following:

The OESIL (Osservatorio Epidemiologica sulla Sincope nel Lazio) risk score was derived in 2003 to predict 1-year mortality in patients presenting with syncope. Mortality increased from 9% for patients with 0 points to 57.1% for patients meeting all 4 criteria (4 points).

The San Francisco Syncope Rule (SFSR) considers the presence of any of 5 features to indicate high risk. It was derived in 2004 to predict serious outcomes within 7 days and was reported to be 96% sensitive and 62% specific in derivation and 98% in prospective validation. Subsequent studies looked at 30-day outcomes. External validation studies found the sensitivity as low as 76%, and strict application of the rule may actually increase rather than decrease admissions.

The Boston Syncope Criteria (BSC) consist of 25 features divided into 7 categories; any single feature is considered to indicate high risk. It was derived in 2007 and found to be 97% sensitive and 62% specific for adverse outcomes at 1 month. The lack of external validation and large number of criteria may limit its use in the ED or other settings.

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Guidelines

2017 guidelines by the AHA/American College of Cardiology (ACC)59 and 2018 guidelines by the ESC support the use of a detailed history, physical examination, and ECG as the initial evaluation. In any setting, risk stratification rather than diagnosis should be performed in patients for whom the etiology remains uncertain. The use of clinical decision tools is considered reasonable, although outcomes in studies correlate strongly with the etiology assigned in the ED, and clinical decision tools should not replace physician judgment.

Online tools for risk stratification for syncope are available at MDCalc:

Elderly Patients

The evaluation of syncope in older adults is particularly challenging, as many do not present with syncope, but rather with unexplained falls. Older adults are more likely to have underlying high-risk medical conditions, yet may still have benign causes of syncope. One-fourth of adults aged >50 years who present to the ED with a fall have symptoms suggestive of syncope or unexplained fall. There is no firm patient age that mandates an ED transfer or hospital admission following an episode of syncope, as the features of the event as well as other patient risk factors influence decision-making. However, it is reasonable to consider ED transfer for monitoring and cardiac biomarkers in patients >50 years who present with unexplained syncope. A 2016 study found almost half of older adults with dementia referred for unexplained falls received a diagnosis of syncope, and neurally mediated syncope is common in this age group. QTc prolongation may occur in 25% of elderly patients; increasing age or QTc >500 ms may predict 30-day and 1-year mortality.

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References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

  1. Sun BC, Emond JA, Camargo CA, Jr. Characteristics and admission patterns of patients presenting with syncope to U.S. emergency departments, 1992-2000. Acad Emerg Med. 2004;11(10):1029-1034 . (Database analysis)
  2. Kadri AN, Abuamsha H, Nusairat L, et al. Causes and predictors of 30-day readmission in patients with syncope/collapse: a nationwide cohort study. J Am Heart Assoc. 2018;7(18):e009746 . (Database analysis)
  3. Joy PS, Kumar G, Olshansky B. Syncope: outcomes and conditions associated with hospitalization. Am J Med. 2017;130(6):699-706.e696 . (Database analysis)
  4. Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883-1948 . (Guidelines)
  5. Ozturk K, Soylu E, Bilgin C, et al. Predictor variables of abnormal imaging findings of syncope in the emergency department. Int J Emerg Med. 2018;11(1):16 . (Retrospective; 1230 patients)
  6. Gatzoulis KA, Karystinos G, Gialernios T, et al. Correlation of noninvasive electrocardiography with invasive electrophysiology in syncope of unknown origin: implications from a large syncope database. Ann Noninvasive Electrocardiol. 2009;14(2):119-127 . (Retrospective; 421 patients)
  7. Chiu DT, Shapiro NI, Sun BC, et al. Are echocardiography, telemetry, ambulatory electrocardiography monitoring, and cardiac enzymes in emergency department patients presenting with syncope useful tests? A preliminary investigation. J Emerg Med. 2014;47(1):113-118 . (Prospective observational; 570 patients)
  8. Anderson KL, Limkakeng A, Damuth E, et al. Cardiac evaluation for structural abnormalities may not be required in patients presenting with syncope and a normal ECG result in an observation unit setting. Ann Emerg Med. 2012;60(4):478-484.e471 . (Retrospective; 323 patients)
  9. AlJaroudi WA, Alraies MC, Wazni O, et al. Yield and diagnostic value of stress myocardial perfusion imaging in patients without known coronary artery disease presenting with syncope. Circ Cardiovasc Imaging. 2013;6(3):384-391 . (Retrospective; 700 patients)
  10. Viau JA, Chaudry H, Hannigan A, et al. The yield of computed tomography of the head among patients presenting with syncope: a systematic review. Acad Emerg Med. 2019;26(5):479-490 . (Meta-analysis; 3361 patients)
  11. Deif B, Kang S, Ismail A, et al. Application of syncope guidelines in the emergency department do not reduce admission rates: a retrospective cohort study. Can J Cardiol. 2018;34(9):1158-1164 . (Retrospective; 1031 patients)
  12. Sun BC, Mangione CM, Merchant G, et al. External validation of the San Francisco Syncope Rule. Ann Emerg Med. 2007;49(4):420-427, 427.e421-424 . (Prospective observational; 477 patients)
  13. Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347(12):878-885 . (Retrospective; 727 patients)
  14. Derose SF, Gabayan GZ, Chiu VY, et al. Patterns and preexisting risk factors of 30-day mortality after a primary discharge diagnosis of syncope or near syncope. Acad Emerg Med. 2012;19(5):488-496 . (Retrospective; 22,189 patients)
  15. 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 . (Meta-analysis; 43,315 patients)
  16. Del Rosso A, Alboni P, Brignole M, et al. Relation of clinical presentation of syncope to the age of patients. Am J Cardiol. 2005;96(10):1431-1435 . (Prospective; 485 patients)
  17. Shiyovich A, Munchak I, Zelingher J, et al. Admission for syncope: evaluation, cost and prognosis according to etiology. Isr Med Assoc J. 2008;10(2):104-108 . (Retrospective; 376 patients)
  18. Sarasin FP, Louis-Simonet M, Carballo D, et al. Prevalence of orthostatic hypotension among patients presenting with syncope in the ED. Am J Emerg Med. 2002;20(6):497-501 . (Prospective observational; 650 patients)
  19. White JL, Hollander JE, Chang AM, et al. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: a multicenter observational study. Am J Emerg Med. 2019;37(12):2215-2223 . (Prospective observational; 1974 patients)
  20. Ruwald MH, Ruwald AC, Jons C, et al. Evaluation of the CHADS2 risk score on short- and long-term all-cause and cardiovascular mortality after syncope. Clin Cardiol. 2013;36(5):262-268 . (Database analysis)
  21. Hoefnagels WA, Padberg GW, Overweg J, et al. Transient loss of consciousness: the value of the history for distinguishing seizure from syncope. J Neurol. 1991;238(1):39-43 . (Prospective observational; 94 patients)
  22. Shmuely S, Bauer PR, van Zwet EW, et al. Differentiating motor phenomena in tilt-induced syncope and convulsive seizures. Neurology. 2018;90(15):e1339-e1346 . (Prospective observational; 115 patients)
  23. Sheldon R, Rose S, Ritchie D, et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002;40(1):142-148 . (Prospective observational; 539 patients)
  24. Brigo F, Nardone R, Ausserer H, et al. The diagnostic value of urinary incontinence in the differential diagnosis of seizures. Seizure. 2013;22(2):85-90 . (Meta-analysis; 473 patients)
  25. Toarta C, Mukarram M, Arcot K, et al. Syncope prognosis based on emergency department diagnosis: a prospective cohort study. Acad Emerg Med. 2018;25(4):388-396 . (Prospective observational; 5010 patients)
  26. Sud S, Klein GJ, Skanes AC, et al. Predicting the cause of syncope from clinical history in patients undergoing prolonged monitoring. Heart Rhythm. 2009;6(2):238-243 . (Prospective; 119 patients)
  27. Chang AM, Hollander JE, Su E, et al. Recurrent syncope is not an independent risk predictor for future syncopal events or adverse outcomes. Am J Emerg Med. 2019;37(5):869-872 . (Prospective observational; 3580 patients)
  28. Solbiati M, Casazza G, Dipaola F, et al. Syncope recurrence and mortality: a systematic review. Europace. 2015;17(2):300-308 . (Meta-analysis; 11,158 patients)
  29. Aydin MA, Maas R, Mortensen K, et al. Predicting recurrence of vasovagal syncope: a simple risk score for the clinical routine. J Cardiovasc Electrophysiol. 2009;20(4):416-421 . (Prospective observational; 276 patients)
  30. Anpalahan M, Gibson S. The prevalence of neurally mediated syncope in older patients presenting with unexplained falls. Eur J Intern Med. 2012;23(2):e48-52 . (Prospective; 200 patients)
  31. Bhangu J, Hall P, Devaney N, et al. The prevalence of unexplained falls and syncope in older adults presenting to an Irish urban emergency department. Eur J Emerg Med. 2019;26(2):100-104 . (Prospective observational; 561 patients)
  32. Ungar A, Mussi C, Ceccofiglio A, et al. Etiology of syncope and unexplained falls in elderly adults with dementia: Syncope and Dementia (SYD) Study. J Am Geriatr Soc. 2016;64(8):1567-1573 . (Prospective observational; 357 patients)
  33. Okamura H, Kamakura T, Morita H, et al. Risk stratification in patients with Brugada syndrome without previous cardiac arrest – prognostic value of combined risk factors. Circ J. 2015;79(2):310-317 . (Retrospective; 218 patients)
  34. Sarkozy A, Sorgente A, Boussy T, et al. The value of a family history of sudden death in patients with diagnostic type I Brugada ECG pattern. Eur Heart J. 2011;32(17):2153-2160 . (Prospective observational; 280 patients)
  35. Thiruganasambandamoorthy V, Stiell IG, Wells GA, et al. Outcomes in presyncope patients: a prospective cohort study. Ann Emerg Med. 2015;65(3):268-276.e266 . (Prospective observational; 881 patients)
  36. Roncon L, Zuin M, Casazza F, et al. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018;54:27-33 . (Prospective; 1716 patients)
  37. Aro AL, Rusinaru C, Uy-Evanado A, et al. Syncope and risk of sudden cardiac arrest in coronary artery disease. Int J Cardiol. 2017;231:26-30 . (Case control; 2119 patients)
  38. Kapoor WN, Peterson J, Wieand HS, et al. Diagnostic and prognostic implications of recurrences in patients with syncope. Am J Med. 1987;83(4):700-708 . (Prospective observational; 433 patients)
  39. Sun BC, Hoffman JR, Mower WR, et al. Low diagnostic yield of electrocardiogram testing in younger patients with syncope. Ann Emerg Med. 2008;51(3):240-246, 246.e241 . (Prospective observational; 477 patients)
  40. Nishijima DK, Lin AL, Weiss RE, et al. ECG predictors of cardiac arrhythmias in older adults with syncope. Ann Emerg Med. 2018;71(4):452-461.e453 . (Prospective observational; 3416 patients)
  41. Pérez-Rodon J, Martínez-Alday J, Barón-Esquivias G, et al. Prognostic value of the electrocardiogram in patients with syncope: data from the group for syncope study in the emergency room (GESINUR). Heart Rhythm. 2014;11(11):2035-2044 . (Retrospective observational; 524 patients)
  42. Grossman SA, Fischer C, Lipsitz LA, et al. Predicting adverse outcomes in syncope. J Emerg Med. 2007;33(3):233-239 . (Prospective observational; 362 patients)
  43. DeLorenzo R. Syncope. In: Marx J, Hockberger R, Walls R, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5 ed: Mosby; 2002 . (Textbook chapter)

    44. th

  44. Thiruganasambandamoorthy V, Sivilotti MLA, Rowe BH, et al. Prevalence of pulmonary embolism among emergency department patients with syncope: a multicenter prospective cohort study. Ann Emerg Med. 2019;73(5):500-510 . (Prospective observational; 9091 patients)
  45. Costantino G, Ruwald MH, Quinn J, et al. Prevalence of pulmonary embolism in patients with syncope. JAMA Intern Med. 2018;178(3):356-362 . (Database analysis)
  46. Oqab Z, Ganshorn H, Sheldon R. Prevalence of pulmonary embolism in patients presenting with syncope. A systematic review and meta-analysis. Am J Emerg Med. 2018;36(4):551-555 . (Meta-analysis; 7583 patients)
  47. Raynal PA, Cachanado M, Truchot J, et al. Prevalence of pulmonary embolism in emergency department patients with isolated syncope: a prospective cohort study. Eur J Emerg Med. 2019;26(6):458-461 . (Prospective; 411 patients)
  48. Stockley CJ, Reed MJ, Newby DE, et al. The utility of routine D-dimer measurement in syncope. Eur J Emerg Med. 2009;16(5):256-260 . (Prospective; 237 patients)
  49. Kelly C, Bledsoe JR, Woller SC, et al. Diagnostic yield of pulmonary embolism testing in patients presenting to the emergency department with syncope. Res Pract Thromb Haemost. 2020;4(2):263-268 . (Retrospective; 32,440 patients)
  50. Chou SC, Nagurney JM, Weiner SG, et al. Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy. Am J Emerg Med. 2019;37(6):1037-1043 . (Database analysis)
  51. İdil H, Kılıc TY. Diagnostic yield of neuroimaging in syncope patients without high-risk symptoms indicating neurological syncope. Am J Emerg Med. 2019;37(2):228-230 . (Retrospective; 1114 patients)
  52. Gabayan GZ, Derose SF, Asch SM, et al. Predictors of short-term (seven-day) cardiac outcomes after emergency department visit for syncope. Am J Cardiol. 2010;105(1):82-86 . (Database analysis; 35,340 patients)
  53. Ricci F, Sutton R, Palermi S, et al. Prognostic significance of noncardiac syncope in the general population: a systematic review and meta-analysis. J Cardiovasc Electrophysiol. 2018;29(12):1641-1647 . (Meta-analysis; 38,843 patients)
  54. Colivicchi F, Ammirati F, Melina D, et al. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J. 2003;24(9):811-819 . (Prospective; 270 patients derivation, 328 validation)
  55. Quinn JV, Stiell IG, McDermott DA, et al. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004;43(2):224-232 . (Prospective; 684 patients)
  56. Quinn J, McDermott D, Stiell I, et al. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006;47(5):448-454 . (Prospective; 791 patients)
  57. Saccilotto RT, Nickel CH, Bucher HC, et al. San Francisco Syncope Rule to predict short-term serious outcomes: a systematic review. Cmaj. 2011;183(15):E1116-1126 . (Meta-analysis; 5316 patients)
  58. Birnbaum A, Esses D, Bijur P, et al. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008;52(2):151-159 . (Prospective observational; 743 patients)
  59. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2017;70(5):e39-e110 . (Guidelines)
  60. Albassam OT, Redelmeier RJ, Shadowitz S, et al. Did this patient have cardiac syncope?: The Rational Clinical Examination Systematic Review. Jama. 2019;321(24):2448-2457 . (Meta-analysis; 4317 patients)
  61. White JL, Chang AM, Hollander JE, et al. QTc prolongation as a marker of 30-day serious outcomes in older patients with syncope presenting to the emergency department. Am J Emerg Med. 2019;37(4):685-689 . (Prospective observational; 2609 patients)
  62. Bo M, Ceccofiglio A, Mussi C, et al. Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope. Eur J Intern Med. 2019;61:34-39 . (Prospective observational; 432 patients)
  63. Massin MM, Bourguignont A, Coremans C, et al. Syncope in pediatric patients presenting to an emergency department. J Pediatr. 2004;145(2):223-228 . (Prospective observational; 226 patients)
  64. Sanatani S, Chau V, Fournier A, et al. Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association position statement on the approach to syncope in the pediatric patient. Can J Cardiol. 2017;33(2):189-198 . (Review article)
  65. Goble MM, Benitez C, Baumgardner M, et al. ED management of pediatric syncope: searching for a rationale. Am J Emerg Med. 2008;26(1):66-70 . (Retrospective; 140 patients)
  66. Mussi C, Ungar A, Salvioli G, et al. Orthostatic hypotension as cause of syncope in patients older than 65 years admitted to emergency departments for transient loss of consciousness. J Gerontol A Biol Sci Med Sci. 2009;64(7):801-806 . (Prospective; 259 patients)
  67. Schaffer JT, Keim SM, Hunter BR, et al. Do orthostatic vital signs have utility in the evaluation of syncope? J Emerg Med. 2018;55(6):780-787 . (Review article)
  68. Probst MA, Lin MP, Sze JJ, et al. Shared decision making for syncope in the emergency department: a randomized controlled feasibility trial. Acad Emerg Med. 2020;27(9):853-865 . (Randomized controlled trial; 50 patients)
  69. Barbic F, Dipaola F, Casazza G, et al. Syncope in a working-age population: recurrence risk and related risk factors. J Clin Med. 2019;8(2) . (Prospective observational; 348 patients)
  70. Sorajja D, Nesbitt GC, Hodge DO, et al. Syncope while driving: clinical characteristics, causes, and prognosis. Circulation. 2009;120(11):928-934 . (Case-control; 381 patients)
  71. Thiruganasambandamoorthy V, Hess EP, Alreesi A, et al. External validation of the San Francisco Syncope Rule in the Canadian setting. Ann Emerg Med. 2010;55(5):464-472 . (Retrospective; 490 patients)
  72. Serrano LA, Hess EP, Bellolio MF, et al. Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2010;56(4):362-373.e361 . (Meta-analysis; 10,994 patients)
  73. Barón-Esquivias G, Fernández-Cisnal A, Arce-León Á, et al. Prognosis of patients with syncope seen in the emergency room department: an evaluation of four different risk scores recommended by the European Society of Cardiology guidelines. Eur J Emerg Med. 2017;24(6):428-434 . (Prospective observational; 323 patients)

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