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Cited by 88Cardiovascular Syncope and Autonomic DisordersEmergency and Acute Care StudiesClinical Reasoning and Diagnostic Skills

External validation of the San Francisco Syncope Rule in the Canadian setting

Thiruganasambandamoorthy, Venkatesh, Hess, Erik P., Alreesi, Abdullah, Perry, Jeffrey J., Wells, George A., Stiell, Ian G.·2010·Annals of Emergency Medicine
DOI 10.1016/j.annemergmed.2009.10.001
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Abstract

Study objective Syncope is a common disposition challenge for emergency physicians. Among the risk-stratification instruments available, only the San Francisco Syncope Rule is rigorously developed. We evaluate its performance in Canadian emergency department (ED) syncope patients.Methods This retrospective review included patients aged 16 years or older who fulfilled the definition of syncope (transient loss of consciousness with complete recovery) and presented to a tertiary care ED during an 18-month period. We excluded patients with ongoing altered mental status, alcohol/illicit drug use, seizure, and head and severe trauma. Patient characteristics, 5 predictors for the rule (history of congestive heart failure, hematocrit level <30%, abnormal ECG characteristics, shortness of breath, and triage systolic blood pressure <90 mm Hg), and outcomes (as per the original study) were extracted.Results Of 915 visits screened, 505 were included. Forty-nine (9.7%) visits were associated with serious outcomes. The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%). Including monitor abnormalities in the ECG variable would improve sensitivity to 96% (47/49 outcomes; 95% CI 87% to 99%). Although physicians failed to predict 2 deaths, the rule would have predicted all 3 deaths that occurred after ED discharge. Implementing the rule in our setting would increase the admission rate from 12.3% to 69.5%.Conclusion In this retrospective Canadian study, the San Francisco Syncope Rule performed with comparable sensitivity but significantly poorer specificity than previously reported. Implementing the rule would significantly increase admission rates. Further studies to either refine the San Francisco Syncope Rule or develop a new rule are needed.

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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 [70]

  • From 7% to 23% of patients with syncope will experience a serious adverse event within 7-30 days, with about half being evident only after disposition from the emergency department, either while admitted in hospital or after discharge home.

    “From 7% to 23% of patients with syncope will experience a serious adverse event within 7-30 days, with about half being evident only after disposition from the emergency department, either while admitted in hospital or after discharge home. 7-9”

    From Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope (2016) · cites this paper as [7]

  • The San Francisco Syncope Rule performed poorly on external validation at various study sites, which made it unacceptable for adoption into practice.

    “It performed poorly on external validation at various study sites, which made it unacceptable for adoption into practice. 7,12,27”

    From Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope (2016) · cites this paper as [7]

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Authors
Thiruganasambandamoorthy, V., Hess, E. P., Alreesi, A., Perry, J. J., Wells, G. A., & Stiell, I. G.
Affiliations
  • University of Ottawa (CA)
  • Mayo Clinic (US)
ORCID
Venue
Annals of Emergency Medicine
Publisher
Elsevier BV
Published
2010-05
Volume
55
Issue
5
Pages
464-472
ISSN
0196-0644 (ISSN-L)
DOI
10.1016/j.annemergmed.2009.10.001
OpenAlex
W2051656435
Cited by
88
References
28
Citations by year
2025: 1 · 2024: 1 · 2023: 7 · 2022: 2 · 2021: 3 · 2020: 3 · 2019: 5 · 2018: 9 · 2017: 3 · 2016: 3 · 2015: 6 · 2014: 13 · 2013: 7 · 2012: 10
FWCI
8.43
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, risk stratification, external validation, emergency department disposition, sensitivity and specificity, electrocardiographic abnormalities, hospitalization rates
MeSH terms
Adolescent, Adult, Aged, Aged, 80 and over, Diagnostic Tests, Routine, Emergency Medical Services, Female, Hospitalization, Humans, Male, Middle Aged, Monitoring, Physiologic, Ontario, Patient Discharge, Retrospective Studies, Sensitivity and Specificity, Syncope, Treatment Outcome, Practice Guidelines as Topic, Young Adult

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