External validation of the San Francisco Syncope Rule
Open accessAbstract
Study objective We externally validate the ability of the San Francisco Syncope Rule to accurately identify syncope patients who will experience a 7-day serious clinical event.Methods Patients who presented to a single academic emergency department (ED) between 8 am and 10 pm with syncope or near-syncope were prospectively enrolled. Treating physicians recorded the presence or absence of all San Francisco Syncope Rule risk factors. Patients were contacted by telephone at 14 days for a structured interview. A 3-physician panel, blinded to the San Francisco Syncope Rule score, reviewed ED medical records, hospital records, and telephone interview forms to identify predefined serious clinical events. The primary outcome was the ability of the San Francisco Syncope Rule to predict any 7-day serious clinical event. A secondary outcome was the ability of the San Francisco Syncope Rule to predict 7-day serious clinical events that were not identified during the initial ED evaluation.Results Of 592 eligible patients, 477 (81%) provided informed consent. Direct telephone contact or admission/outpatient records were successfully obtained for 463 (97%) patients. There were 56 (12%) patients who had a serious 7-day clinical event, including 16 (3%) who received a diagnosis after the initial ED evaluation. Sensitivity and specificity of the San Francisco Syncope Rule for the primary outcome were 89% (95% confidence interval [CI] 81% to 97%) and 42% (95% CI 37% to 48%), respectively, and 69% (95% CI 46% to 92%) and 42% (95% CI 37% to 48%), respectively, for the secondary outcome. Estimates of sensitivity were minimally affected by missing data and most optimistic assumptions for missing follow-up information.Conclusion In this external validation cohort, the San Francisco Syncope Rule had a lower sensitivity and specificity than in previous reports.
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None of the emergency department syncope clinical decision rules are used widely in emergency departments due to poor sensitivity and specificity reported from external validation, or due to a lack of external validation.
“None of these rules are used widely in EDs due to poor sensitivity and specificity reported from external validation, or due to a lack of external validation. 70,78-85”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [83]
The Discussion (page not provided) reports lower sensitivity and specificity for the San Francisco Syncope Rule in this external validation. The 'How this might change clinical practice' section says the rule requires further external validation before general ED use. The paper does not establish that none of the syncope rules are widely used, or that poor performance or absent validation explains their use across EDs. (LLM, conf=0.86)
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- Authors
- Sun, B. C., Mangione, C. M., Merchant, G., Weiss, T., Shlamovitz, G. Z., Zargaraff, G., Shiraga, S., Hoffman, J. R., & Mower, W. R.
- Affiliations
- University of California, Los Angeles (US)
- Corresponding author
- Sun, Benjamin C.
- Venue
- Annals of Emergency Medicine
- Publisher
- Elsevier BV
- Published
- 2007-04
- Volume
- 49
- Issue
- 4
- Pages
- 420-427.e4
- ISSN
- 0196-0644 (ISSN-L)
- OpenAlex
- W2163991175
- Cited by
- 128
- References
- 20
- Citations by year
- 2025: 2 · 2024: 2 · 2023: 4 · 2022: 3 · 2021: 2 · 2020: 4 · 2019: 4 · 2018: 9 · 2017: 4 · 2016: 10 · 2015: 7 · 2014: 9 · 2013: 11 · 2012: 9
- FWCI
- 12.61
- Type
- journal article
- Language
- en
- Open access
- green
- escholarship.org
- Locations
- Annals of Emergency Medicine (publishedVersion)
- PubMed (publishedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- U.S. Department of Veterans Affairs
- National Institutes of Health
- National Institute on Aging (AG-02-004, K12AG001004)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- San Francisco Syncope Rule, syncope, presyncope, risk prediction, external validation, sensitivity and specificity, emergency department, telephone follow-up
- MeSH terms
- Adult, Aged, Aged, 80 and over, Clinical Protocols, Emergency Medicine, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Predictive Value of Tests, Prospective Studies, Risk Factors, San Francisco, Sensitivity and Specificity, Syncope, Outcome Assessment, Health Care, Risk Assessment
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