Evaluation of prognostic classifications for patients with syncope

doi:10.1016/0002-9343(85)90032-4

The American Journal of Medicine

Volume 79, Issue 4, October 1985, Pages 455-460

https://doi.org/10.1016/0002-9343(85)90032-4 Get rights and content

Abstract

To evaluate two published sets of prognostic classifications for patients with syncope, 176 consecutive patients who presented to an emergency room with syncope were studied. Although relatively few patients had cardiac syncope, these data confirmed their high one-year mortality. At the other extreme, it was also confirmed that patients who were 30 years of age or less or 70 years of age or less and had vasovagal/psychogenic syncope or syncope of unknown cause had a benign prognosis, with only two deaths in 225 patients in pooled data. However, these data did not confirm the previously reported prognoses for “medium-risk patients” or for patients with diagnosable noncardiovascular causes of syncope, largely because of differences in criteria for patient eligibility. It is concluded that available data allow over 70 percent of patients with syncope to be placed into either very-high or very-low-risk groups. However, further investigation, taking into account differences in patient selection criteria, will be required before accurate prognostic classifications can be derived for the nearly 30 percent of patients who do not fall into one of these extreme prognostic categories.

References (26)

WN Kapoor et al.
Syncope of unknown origin
SC Day et al.
Evaluation and outcome of emergency room patients with transient loss of consciousness
Am J Med
(1982)
MD Silverstein et al.
Patients with syncope admitted to medical intensive care units
JAMA
(1982)
KA Eagle et al.
The impact of diagnostic tests in evaluating patients with syncope
Yale J Biol Med
(1983)
WN Kapoor et al.
A prospective evaluation and follow-up of patients with syncope
N Engl J Med
(1983)
GJ Martin et al.
Prospective evaluation of syncope
Ann Emerg Med
(1984)
JD Kalbfleisch et al.
The statistical analysis of failure time data
(1980)
R Peto et al.
Design and analysis of randomized clinical trials requiring prolonged observation of each patient
Br J Cancer
(1976)
AR Feinstein
Clinical biostatistics
(1977)
of Clinical Epidemiology and Biostatistics, McMaster University Department et al.
How to read clinical journals: Ill. To learn the clinical course and prognosis of disease
Can Med Assoc J
(1981)

DL Sackett

Bias in analytic research

J Chronic Dis

(1979)

S Jonas et al.

Importance of Holter monitoring in patients with periodic cerebral symtpoms

Ann Neurol

(1977)

D Tzivoni et al.

Pacemaker implantation based on ambulatory ECG monitoring in patients with cerebral symptoms

Chest

(1975)

Cited by (127)

Diagnostic algorithm for syncope
2014, Autonomic Neuroscience: Basic and Clinical
Syncope is a common symptom with many causes. Affecting a large proportion of the population, both young and old, it represents a significant healthcare burden. The diagnostic approach to syncope should be focused on the initial evaluation, which includes a detailed clinical history, physical examination and 12-lead electrocardiogram. Following the initial evaluation, patients should be risk-stratified into high or low-risk groups in order to guide further investigations and management. Patients with high-risk features should be investigated further to exclude significant structural heart disease or arrhythmia. The ideal currently-available investigation should allow ECG recording during a spontaneous episode of syncope, and when this is not possible, an implantable loop recorder may be considered. In the emergency room setting, acute causes of syncope must also be considered including severe cardiovascular compromise due to pulmonary, cardiac or vascular pathology. While not all patients will receive a conclusive diagnosis, risk-stratification in patients to guide appropriate investigations in the context of a diagnostic algorithm should allow a benign prognosis to be maintained.
Recognizing life-threatening causes of syncope
2013, Cardiology Clinics
Citation Excerpt :
Chief among these is the identification of either a structural or electrical cardiac etiology for the syncopal episode. In early retrospective analyses of patients with syncope, cardiac syncope was associated with a 21% to 30% mortality rate at 1 year versus 4% to 12% in those with noncardiac syncope.2,6 A more recent study has suggested a more conservative 15% mortality rate at 1 year in patients with cardiac syncope.7
Syncope. Evaluation and Management in the Geriatric Patient.
2012, Clinics in Geriatric Medicine
San Francisco Syncope Rule, Osservatorio Epidemiologico sulla Sincope nel Lazio risk score, and clinical judgment in the assessment of short-term outcome of syncope
2010, American Journal of Emergency Medicine
The study aimed to compare the efficacy of the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score, San Francisco Syncope Rule, and clinical judgment in assessing the short-term prognosis of syncope.
We studied 488 patients consecutively seen for syncope at the emergency department of 2 general hospitals between January and July 2004. Sensitivity, specificity, predictive values, and likelihood ratios for short-term (within 10 days) severe outcomes were computed for each decision rule and clinical judgment. Severe outcomes comprised death, major therapeutic procedures, and early readmission to hospital.
Clinical judgment had a sensitivity of 77%, a specificity of 69%, and would have admitted less patients (34%, P < .05 vs decision rules). The OESIL risk score was characterized by a sensitivity of 88% and a specificity of 60% (admission 43%). San Francisco Syncope Rule sensitivity was 81% and specificity was 63% (admission 40%). According to both clinical rules, no discharged patient would have died. With combined OESIL risk score and clinical judgment, the probability of adverse events was 0.7% for patients with both low risk scores, whereas that for both high risk scores was roughly 16%.
Because of a relatively low sensitivity, both risk scores were partially lacking in recognizing patients with short-term high-risk syncope. However, the application of the decision rules would have identified all patients who subsequently died, and OESIL risk score and clinical judgment combined seem to improve the decision-making process concerning the identification of high-risk patients who deserve admission.
Prospective evaluation of psychological distress and psychiatric morbidity in recurrent vasovagal and unexplained syncope
2009, Journal of Psychosomatic Research
Syncope is experienced by a third of the population, and in the absence of cardiac pathology is most commonly of vasovagal (VVS) or unexplained origin (US). Psychiatric morbidity has been observed in up to 81% of patients with US but findings with VVS are contradictory. Little is known regarding the chronicity of their psychiatric morbidity.
To determine the psychological profile of patients with recurrent syncope prior to and following diagnostic head-up tilt testing (HUT), and whether it predicts syncope recurrence.
Seventy-three women and 43 men (mean age=48±16.6) were recruited from all consenting patients referred for HUT. Psychological status (Psychiatric Symptom Index, Anxiety Sensitivity Index (ASI), Fear of Blood Injury Subscale) and presence of mood/anxiety disorders (Primary Care Evaluation of Mental Disorders) were evaluated 1 month prior to and 6 months following HUT. Follow-up data were collected for 83 patients (mean age=48±17.34).
At baseline, clinically significant levels of distress were observed in 60% of patients. Those with US (negative HUT) had a fivefold greater risk of suffering from a depressive or anxiety disorder compared to VVS (positive HUT) after controlling for significant covariates. There was no significant change in distress level over follow-up, although psychiatric morbidity dropped from 33% to 22% (P=.049). Syncope recurrence was predicted by elevations in baseline psychological distress (OR=1.544, P=.013) independently of lifetime number of syncopes.
Patients exhibited high levels of psychological distress and psychiatric morbidity despite reassurance and education received after HUT. Improved screening for and treatment of psychological distress in these patients is critical.
Short- and Long-Term Prognosis of Syncope, Risk Factors, and Role of Hospital Admission. Results From the STePS (Short-Term Prognosis of Syncope) Study
2008, Journal of the American College of Cardiology
Citation Excerpt :
We hypothesize that the prompt identification of short-term risk factors may help emergency physicians in their decision making process and in turn reduce the number of inappropriate hospital admission. A number of studies have addressed the problem of syncope prognosis, highlighting its remarkable variability according to the different causes that underlie the loss of consciousness (1,3,4,18–20). In particular, cardiac syncope was characterized by the worst prognosis (1) compared with the virtual absence of mortality at 12 months in the case of vasovagal events (1,3,5).
We sought to assess short- and long-term prognosis of syncope and associated risk factors.
Syncope is a common clinical event, but our knowledge of its short-term outcome is largely incomplete. Further, it is unknown whether hospital admission might positively affect a patient’s syncope prognosis.
We screened 2,775 consecutive subjects who presented for syncope at 4 emergency departments between January and July 2004. Short- and long-term severe outcomes (i.e., death and major therapeutic procedures) and related risk factors were compared in all enrolled patients arrayed according to hospital admission or discharge.
A total of 676 subjects were included in the study. Forty-one subjects (6.1%) experienced severe outcomes (5 deaths, 0.7%; 36 major therapeutic procedures, 5.4%) in the 10 days after presentation. An abnormal electrocardiogram, concomitant trauma, absence of symptoms of impending syncope, and male gender were associated with short-term unfavorable outcomes. Long-term severe outcomes were 9.3% (40 deaths, 6.0%; 22 major therapeutic procedures, 3.3%), and their occurrence was correlated with an age >65 years, history of neoplasms, cerebrovascular diseases, structural heart diseases, and ventricular arrhythmias. Short-term major therapeutic procedures were more common (p < 0.05) in subjects who had been admitted to hospital (13.3%) than in discharged (1.6%), whereas mortality was similar. One-year mortality was greater (p < 0.05) in admitted (14.7%) than in discharged (1.8%) patients.
Risk factors for short- and long-term adverse outcomes after syncope differed. Hospital admission favorably influenced syncope short term prognosis. Instead, 1-year mortality was unaffected by hospital admission and related to comorbidity.

View all citing articles on Scopus

^☆: This work was supported in part by a grant (83102-2H) from the John A. Hartford Foundation, New York, New York.

^☆☆: A continuing medical education quiz on this article (one hour of Category 1 credit) appears on page A129 of this issue.

¹: Dr. Goldman is a Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine.

View full text

Evaluation of prognostic classifications for patients with syncope☆,☆☆

Abstract

Syncope of unknown origin

Evaluation and outcome of emergency room patients with transient loss of consciousness

Am J Med

Patients with syncope admitted to medical intensive care units

JAMA

The impact of diagnostic tests in evaluating patients with syncope

Yale J Biol Med

A prospective evaluation and follow-up of patients with syncope

N Engl J Med

Prospective evaluation of syncope

Ann Emerg Med

The statistical analysis of failure time data

Design and analysis of randomized clinical trials requiring prolonged observation of each patient

Br J Cancer

Clinical biostatistics

How to read clinical journals: Ill. To learn the clinical course and prognosis of disease