The ROSE (Risk Stratification of Syncope in the Emergency Department) Study
Open accessAbstract
Objectives The aim of this study was to develop and validate a clinical decision rule (CDR) to predict 1-month serious outcome and all-cause death in patients presenting with syncope to the emergency department.Background Syncope is a common, potentially serious condition accounting for many hospital admissions.Methods This was a single center, prospective, observational study of adults presenting to the emergency department with syncope. A CDR was devised from 550 patients in a derivation cohort and tested in a validation cohort of a further 550 patients.Results One-month serious outcome or all-cause death occurred in 40 (7.3%) patients in the derivation cohort. Independent predictors were brain natriuretic peptide concentration > or =300 pg/ml (odds ratio [OR]: 7.3), positive fecal occult blood (OR: 13.2), hemoglobin < or =90 g/l (OR: 6.7), oxygen saturation < or =94% (OR: 3.0), and Q-wave on the presenting electrocardiogram (OR: 2.8). One-month serious outcome or all-cause death occurred in 39 (7.1%) patients in the validation cohort. The ROSE (Risk stratification Of Syncope in the Emergency department) rule had a sensitivity and specificity of 87.2% and 65.5%, respectively, and a negative predictive value of 98.5%. An elevated B-type natriuretic peptide (BNP) concentration alone was a major predictor of serious cardiovascular outcomes (8 of 22 events, 36%) and all-cause deaths (8 of 9 deaths, 89%).Conclusions The ROSE rule has excellent sensitivity and negative predictive value in the identification of high-risk patients with syncope. As a component, BNP seems to be a major predictor of serious cardiovascular outcomes and all-cause death. The ROSE rule and BNP measurement might be valuable risk stratification tools in patients with emergency presentations of syncope and should now be subjected to external validation.
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None of the different risk stratification tools developed and tested so far have definitely proved to perform better than clinical judgment.
“Different risk stratification tools have been developed and tested so far but none have definitely proved to perform better than clinical judgment. 1,9,13,14”
From Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department (2016) · cites this paper as [14]
The Conclusions describe several syncope risk-stratification studies and note limitations in their validation. The ROSE Study section says a decision rule should be used alongside physician judgment, but the paper does not establish the broader claim that no tool has proved better than clinical judgment. Page numbers are not supplied for these passages. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe ROSE rule performed suboptimally when validated and requires B-type natriuretic peptide testing, which is not easily available in many emergency departments.
“The rule performed suboptimally when validated and requires B-type natriuretic peptide testing, which is not easily available in many emergency departments.”
From Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope (2016) · cites this paper as [9]
The ROSE rule (Discussion; page not specified) includes a BNP threshold, and the paper says only 5% of UK emergency departments had point-of-care BNP testing. The validation results (Performance of the ROSE rule; page not specified) report five missed patients, but the authors describe the rule’s sensitivity as excellent, say external validation was still needed, and note that almost all UK emergency departments had rapid access to laboratory BNP. The paper therefore does not fully support the characterization of validated performance as suboptimal or BNP testing as generally difficult to obtain. (LLM, conf=0.86)
Experimental — accuracy not yet measuredInclusion of patients with serious adverse events identified in the emergency department introduces bias in the tool.
“Inclusion of patients with serious adverse events identified in the emergency department introduces bias in the tool”
From Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope (2016) · cites this paper as [9]
The ROSE Study section reports that patients whose serious outcomes were apparent at initial ED assessment were included, and says the rule should be applied when a clear diagnosis is not apparent. It does not state that including those patients introduced bias into the tool. (LLM, conf=0.85)
Experimental — accuracy not yet measuredMany (40-45%) non-cardiovascular and some cardiovascular life-threatening underlying conditions are obvious in the ED.
“Many (40-45%) non-cardiovascular and some cardiovascular life-threatening underlying conditions are obvious in the ED. 44”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [44]
Table 2 in the Discussion reports an obvious diagnosis in the ED for 17 of 40 patients with a primary outcome in the derivation cohort and 16 of 39 in the validation cohort—about 40–45%. Those figures cover serious outcomes or death overall; the table does not establish that 40–45% of non-cardiovascular conditions, specifically, were obvious or show how many obvious diagnoses were cardiovascular. The indexed passage does not provide a page number. (LLM, conf=0.86)
Experimental — accuracy not yet measuredFrom 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 [9]
The Results report a serious outcome or death within one month in 7.3% of the derivation cohort and 7.1% of the validation cohort. The outcome table in the Discussion records an obvious diagnosis in the ED for 17 of 40 and 16 of 39 patients with primary outcomes, consistent with roughly half not being obvious there. The paper does not establish the claimed 23% upper rate or show that those outcomes first became evident only after ED disposition, whether in hospital or at home. (LLM, conf=0.85)
Experimental — accuracy not yet measured
The existing clinical decision tools for syncope have poor diagnostic test characteristics and several methodological flaws that preclude their widespread adoption by clinicians.
“However, they have poor diagnostic test characteristics and several methodological flaws that preclude their widespread adoption by clinicians.”
From Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope (2016) · cites this paper as [9]
The Discussion (page not supplied) says existing syncope decision rules could not avoid admissions without an unacceptable increase in missed serious outcomes. The Conclusions (page not supplied) identify small derivation cohorts, missing validation, and failed external validation. These support the performance and methodological concerns, but the paper does not establish that those problems preclude widespread adoption by clinicians. (LLM, conf=0.83)
Experimental — accuracy not yet measuredA few prospective studies developed clinical decision tools to identify patients at risk of serious adverse events within 30 days.
“A few prospective studies developed clinical decision tools to identify patients at risk of serious adverse events within 30 days. 8,9,13,14”
From Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope (2016) · cites this paper as [9]
Five prospective syncope studies attempted to develop tools for identification of short-term risk of serious adverse events.
“Five prospective syncope studies attempted to develop tools for identification of short-term risk of serious adverse events. 8,9,13,14,26”
From Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope (2016) · cites this paper as [9]
The ROSE rule was developed to predict serious adverse events within 1 month.
“The Risk Stratification of Syncope in the Emergency Department (ROSE) rule was developed to predict serious adverse events within 1 month. 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 [9]
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- Authors
- Reed, M. J., Newby, D. E., Coull, A. J., Prescott, R. J., Jacques, K. G., & Gray, A. J.
- Affiliations
- Edinburgh Royal Infirmary (GB)
- University of Edinburgh (GB)
- Corresponding author
- Reed, Matthew J.
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2010-02
- Volume
- 55
- Issue
- 8
- Pages
- 713-721
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2092319060
- Cited by
- 272
- References
- 28
- Citations by year
- 2026: 6 · 2025: 10 · 2024: 7 · 2023: 13 · 2022: 4 · 2021: 15 · 2020: 18 · 2019: 17 · 2018: 32 · 2017: 22 · 2016: 17 · 2015: 16 · 2014: 32 · 2013: 27 · 2012: 16
- FWCI
- 21.23
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Edinburgh Research Explorer (University of Edinburgh) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Keywords
- syncope, clinical decision rules, risk stratification, brain natriuretic peptide, all-cause mortality, fecal occult blood, hemoglobin, oxygen saturation, Q waves, emergency department, cardiovascular risk prediction
- MeSH terms
- Adult, Aged, Cause of Death, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Predictive Value of Tests, Prospective Studies, Risk Factors, Sensitivity and Specificity, Syncope, Reproducibility of Results, Risk Assessment, Decision Support Systems, Clinical
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