CoChat
Sign Up
Cited by 148Cardiovascular Syncope and Autonomic DisordersEmergency and Acute Care StudiesClinical Reasoning and Diagnostic Skills

Failure to validate the San Francisco Syncope Rule in an independent emergency department population

Birnbaum, Adrienne, Esses, David, Bijur, Polly, Wollowitz, Andrew, Gallagher, E. John·2008·Annals of Emergency Medicine
DOI 10.1016/j.annemergmed.2007.12.007
Open this paper in CoChat — free account

Abstract

Study objective We conduct a prospective independent validation of the San Francisco Syncope Rule to identify emergency department (ED) syncope patients with short-term serious outcomes.Methods This was a prospective observational cohort study of adult patients presenting to a university hospital ED with acute syncope or near syncope. Patients meeting inclusion criteria as defined in the San Francisco Syncope Rule derivation were evaluated for 5 previously derived predictor variables: abnormal ECG result, shortness of breath, hematocrit level less than 30%, triage systolic blood pressure less than 90 mm Hg, and history of congestive heart failure. Hospital admission occurred at the discretion of the emergency physician, independent of the decision rule. Follow-up occurred through contact with the inpatient attending physician for admitted patients and by telephone contact with patients not hospitalized or those hospitalized and discharged before day 7. Predetermined outcome measures as defined by the San Francisco Syncope Rule were death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing or likely to cause a return ED visit and hospitalization for a related event.Results Complete predictor and follow-up data were available for 713 of 743 (96%) enrolled patients. Sixty-one of 713 (9%) patients met predetermined criteria for serious outcome. Sixteen of 61 (26%; 95% confidence interval [CI] 16% to 39%) patients with a serious outcome were not identified as high risk by the rule. Rule performance to predict serious outcomes was sensitivity 74% (95% CI 61% to 84%), specificity 57% (95% CI 53% to 61%); negative likelihood ratio 0.5 (95% CI 0.3 to 0.7) and positive likelihood ratio 1.7 (95% CI 1.4 to 2.0).Conclusion In this independent validation study, sensitivity and negative likelihood ratio of the San Francisco Syncope Rule were substantially lower than reported in the original studies and suggest that the rule has limited generalizability.

Integrity signals

Registry

Crossref · 10.1016/j.annemergmed.2007.12.007

Cites

20 of 20 references verified0 citation errors · 0 not checkable

Statistics

Recomputing p-values needs the paper’s full text.

Claims the paper makes

This paper’s full text isn’t openly available, so its claims and self-check weren’t run. The registry and citation checks still apply.

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • 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 [85]

Cites

Flagged first, then by citations

1 of the 21 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Birnbaum, A., Esses, D., Bijur, P., Wollowitz, A., & Gallagher, E. J.
Affiliations
Albert Einstein College of Medicine (US)
Corresponding author
Birnbaum, Adrienne
ORCID
Bijur, Polly
Venue
Annals of Emergency Medicine
Publisher
Elsevier BV
Published
2008-08
Volume
52
Issue
2
Pages
151-159
ISSN
0196-0644 (ISSN-L)
DOI
10.1016/j.annemergmed.2007.12.007
OpenAlex
W2025968703
Cited by
148
References
21
Citations by year
2026: 5 · 2025: 3 · 2024: 4 · 2023: 6 · 2022: 2 · 2021: 3 · 2020: 5 · 2019: 6 · 2018: 13 · 2017: 5 · 2016: 7 · 2015: 10 · 2014: 18 · 2013: 12 · 2012: 10
FWCI
13.70
Type
journal article
Language
en
Open access
closed
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Annals of Emergency Medicine (publishedVersion)
  • PubMed (publishedVersion)
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, emergency department, generalizability, risk stratification, myocardial infarction, cardiac arrhythmias, stroke, subarachnoid hemorrhage, pulmonary embolism, hemorrhage
MeSH terms
Adult, Decision Support Techniques, Emergency Service, Hospital, Heart Diseases, Hemorrhage, Humans, Pulmonary Embolism, Sensitivity and Specificity, Syncope, Cohort Studies, Observation

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review