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Personalised risk prediction following emergency department assessment for syncope
  1. Venkatesh Thiruganasambandamoorthy1,2,3,
  2. Justin W Yan4,
  3. Brian H Rowe5,
  4. Éric Mercier6,7,
  5. Natalie Le Sage6,7,
  6. Mona Hegdekar8,
  7. Anne Finlayson8,
  8. Paul Huang9,
  9. Hassan Mohammad10,
  10. Muhammad Mukarram2,
  11. Phuong Anh (Iris) Nguyen2,
  12. Shahbaz Syed1,
  13. Andrew D McRae11,
  14. Marie-Joe Nemnom2,
  15. Monica Taljaard2,3,
  16. Marco LA Silviotti12
  1. 1 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
  2. 2 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  3. 3 School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
  4. 4 Division of Emergency Medicine, Western University, London, Ontario, Canada
  5. 5 Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
  6. 6 Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada
  7. 7 CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
  8. 8 Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
  9. 9 Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  10. 10 Faculty of Technology and Trades, Algonquin College, Ottawa, Ontario, Canada
  11. 11 Department of Emergency Medicine, and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  12. 12 Departments of Emergency Medicine and Biomedical, and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
  1. Correspondence to Dr Venkatesh Thiruganasambandamoorthy, Department of Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, ON K1N 6N5, Canada; vthirug{at}


Background Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions.

Methods We pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids.

Results 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS −3 to –2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score −3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%–6% deaths. The online calculator and the pictorial aids can be found at:

Conclusions 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.

  • syncope
  • emergency department
  • hospitalisations

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  • Handling editor Edward Carlton

  • Twitter @TeamVenk?s=20

  • Contributors VT, JWY, BHR, EM, NLS, MH, PH, MM, ADM, MT and MLAS conceived the idea, contributed to the study design, developed the study protocol and applied for funding. VT, JY, BHR, EM, NLS, MH, AF, PH, MM, PAN, ADM, M-JN, MT and MLAS supervised the conduct of the studies including recruitment of patients, data collection, data management including quality control. MT provided statistical advice on study design. M-JN analysed the data under MT’s supervision. HM, PAN and SS interpreted the results, designed and developed the online calculator, pictograms and patient information materials. VT drafted the manuscript. All authors reviewed the manuscript and contributed substantially to its revision. VT takes responsibility for the paper as a whole.

  • Funding The two prospective studies from which these data were taken were funded by The Physicians’ Services Incorporated Foundation (09q4017), Canadian Institutes of Health Research (MOP-114927), Heart and Stroke Foundation Canada (G-15–0009006), and the Cardiac Arrhythmia Network of Canada (SRG-15-P10-001) as part of the Networks of Centres of Excellence (NCE).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.