J Emerg Med. 2021 Sep 14:S0736-4679(21)00642-9. doi: 10.1016/j.jemermed.2021.07.060. Online ahead of print.
BACKGROUND: Syncope is a common presentation to the emergency department (ED). A significant minority of these patients have potentially life-threatening pathology. Reliably identifying that patients require hospital admission for further workup and intervention is imperative.
CLINICAL QUESTION: In patients who present with syncope, is there a reliable decision tool that clinicians can use to predict the risk of adverse outcome and determine who may be appropriate for discharge?
EVIDENCE REVIEW: Four articles were reviewed. The first retrospective study found no difference in mortality or adverse events in patients admitted for further evaluation rather than discharged home with primary care follow-up. The next two articles examined the derivation and validation of the Canadian Syncope Risk Score (CSRS). After validation with an admission threshold score of -1, the sensitivity and specificity of the CSRS was 97.8% (95% confidence interval [CI] 93.8-99.6%) and 44.3% (95% CI 42.7-45.9%), respectively. The last article looked at the derivation of the FAINT score, a recently developed score to risk stratify syncope patients. A FAINT score of ≥ 1 (any score 1 or higher should be admitted) had a sensitivity of 96.7% (95% CI 92.9-98.8%) and specificity 22.2% (95% CI 20.7-23.8%).
CONCLUSIONS: Syncope remains a difficult chief symptom to disposition from the ED. The CSRS is modestly effective at establishing a low probability of actionable disease or need for intervention. However, CSRS might not reduce unnecessary hospitalizations. The FAINT score has yet to undergo validation; however, the initial derivation study offers less diagnostic accuracy compared with the CSRS.