Usefulness of the Calgary Syncope Symptom Score for the diagnosis of vasovagal syncope in the elderly
Open accessAbstract
AIMS: The Calgary Syncope Symptom Score (CSSS) has been validated as a simple point score of historical features with high sensitivity and specificity for the diagnosis of vasovagal syncope (VVS) in younger populations without evidence of structural heart disease. Our purpose was to evaluate the performance of the CSSS in an elderly population with suspected VVS. METHODS AND RESULTS: Hundred and eighty patients of ≥60 years of age (mean 73.4 ± 7.8) with suspected clinical diagnosis of VVS were studied. The CSSS (VVS score ≥-2) was calculated in all patients prior to undergoing head-up tilt test (HUT). A standardized HUT protocol with active nitroglycerin phase was used to reproduce syncopal symptoms as gold standard for diagnosis of VVS. Hundred and forty patients had positive HUT response. Eighty-three patients (42.3%) had CSSS ≥-2 suggesting a diagnosis of VVS. The Calgary Syncope Symptom Score sensitivity was 0.51 [95% confidence interval (CI) 0.42-0.59] and specificity 0.73 (95% CI 0.52-0.85) with positive predictive value and negative predictive value of 0.87 (95% CI 0.77-0.93) and 0.30 (95% CI 0.21-0.40), respectively. One hundred (55.6%) patients had previous history of mild cardiovascular disease documented during assessment prior to HUT. In this population sensitivity and specificity was markedly reduced: 0.13 (95% CI 0.05-0.29) and 0.70 (95% CI 0.57-0.80), respectively. CONCLUSION: The CSSS has a lower sensitivity and specificity in an elderly population presenting with syncope compared to previously validated data in young adults, particularly in elderly patients with previous history of mild cardiovascular disease. A modified CSSS may be needed to improve specificity and sensitivity in this population.
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Validation attempts for vasovagal syncope diagnostic scores have generally not used patients as rigorously defined as those in the derivation studies.
“Generally, attempts at validation have not been conducted with patients as rigorously defined as in the derivation studies.94,95”
From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [95]
The Discussion (page not provided) says one validation study included patients with other causes of loss of consciousness, which it identifies as a methodological issue. It also contrasts this study’s elderly patients with the original score’s population without structural heart disease. These examples support the concern, but the paper does not establish that validation attempts generally used less rigorously defined patients. (LLM, conf=0.84)
Experimental — accuracy not yet measured
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Cites
Dyck, P. J., Kratz, K. M., Karnes, J. L., Litchy, W. J., Klein, R., Pach, J. M., Wilson, D. M., O'Brien, P. C., & Melton, L. J. (1993) · Neurology · doi:10.1212/wnl.43.4.817 · Cited by 1,482 · see citing works
Incidence and Prognosis of Syncope
Soteriades, E. S., Evans, J. C., Larson, M. G., Chen, M. H., Chen, L., Benjamin, E. J., & Levy, D. (2002) · New England Journal of Medicine · doi:10.1056/nejmoa012407 · Cited by 1,364 · see citing works
The epidemiology of falls and syncope
Rubenstein, L. Z., & Josephson, K. R. (2002) · Clinics in Geriatric Medicine · doi:10.1016/s0749-0690(02)00002-2 · Cited by 1,180 · see citing works
HEAD-UP TILT: A USEFUL TEST FOR INVESTIGATING UNEXPLAINED SYNCOPE
Kenny, R. A., Bayliss, J. M., Ingram, A., & Sutton, R. (1986) · The Lancet · doi:10.1016/s0140-6736(86)91665-x · Cited by 777 · see citing works
Guidelines on Management (diagnosis and treatment) of syncope ? update 2004
Brignole, M., Alboni, P., Benditt, D. G., Bergfeldt, L., Blanc, J., Thomsen, P. E. B., van Dijk, J. G., Fitzpatrick, A. P., Hohnloser, S. H., Janousek, J., et al. (2004) · EP Europace · doi:10.1016/j.eupc.2004.08.008 · Cited by 648 · see citing works
Evaluation and Outcome of Patients with Syncope
KAPOOR, W. N. (1990) · Medicine · doi:10.1097/00005792-199005000-00004 · Cited by 539 · see citing works
Lipsitz, L. A., Mietus, J. E., Moody, G. B., & Goldberger, A. L. (1990) · Circulation · doi:10.1161/01.cir.81.6.1803 · Cited by 519 · see citing works
PASSIVE IMMUNITY AGAINST CHILDHOOD CANCER
Lowry, W. S. (1974) · The Lancet · doi:10.1016/s0140-6736(74)90736-3 · Cited by 518 · see citing works
Age and gender influence muscle sympathetic nerve activity at rest in healthy humans.
Ng, A. V., Callister, R. J., Johnson, D. G., & Seals, D. R. (1993) · Hypertension · doi:10.1161/01.hyp.21.4.498 · Cited by 444 · see citing works
Effect of aging on baroreflex function in humans
Monahan, K. D. (2007) · American Journal of Physiology-Regulatory, Integrative and Comparative Physiology · doi:10.1152/ajpregu.00031.2007 · Cited by 380 · see citing works
Shen, W. K., Decker, W. W., Smars, P. A., Goyal, D. G., Walker, A. E., Hodge, D. O., Trusty, J. M., Brekke, K. M., Jahangir, A., Brady, P. A., et al. (2004) · Circulation · doi:10.1161/01.cir.0000149236.92822.07 · Cited by 318 · see citing works
Bartoletti, A. (2000) · Europace · doi:10.1053/eupc.2000.0125 · Cited by 315 · see citing works
Epidemiology of reflex syncope
Colman, N., Nahm, K., Ganzeboom, K. S., Shen, W.-K., Reitsma, J. B., Linzer, M., Wieling, W., & Kaufmann, H. (2004) · Clinical Autonomic Research · doi:10.1007/s10286-004-1003-3 · Cited by 278 · see citing works
Diagnostic criteria for vasovagal syncope based on a quantitative history
Sheldon, R., Rose, S., Connolly, S., Ritchie, D., Koshman, M.-L., & Frenneaux, M. (2006) · European Heart Journal · doi:10.1093/eurheartj/ehi584 · Cited by 252 · see citing works
Evaluation and Management of the Patient With Syncope
Kapoor, W. N. (1992) · JAMA · doi:10.1001/jama.1992.03490180085031 · Cited by 234 · see citing works
Proposed classification for tilt induced vasovagal syncope
Sutton, R. B. (1992) · Medical Entomology and Zoology · Cited by 230 · see citing works
Vasovagal syncope in medical students and their first-degree relatives
Serletis, A., Rose, S., Sheldon, A. G., & Sheldon, R. S. (2006) · European Heart Journal · doi:10.1093/eurheartj/ehl147 · Cited by 229 · see citing works
Syncope in an Elderly, Institutionalised Population: Prevalence, Incidence, and Associated Risk
LIPSITZ, L. A., WEI, J. Y., & ROWE, J. W. (1985) · QJM: An International Journal of Medicine · doi:10.1093/oxfordjournals.qjmed.a067852 · Cited by 218 · see citing works
Ammirati, F. (2000) · European Heart Journal · doi:10.1053/euhj.1999.1910 · Cited by 205 · see citing works
Lakatta, E. G. (1993) · Circulation · doi:10.1161/01.cir.87.2.631 · Cited by 162 · see citing works
Kenny, R. A., O'Shea, D., & Parry, S. W. (2000) · Heart · doi:10.1136/heart.83.5.564 · Cited by 148 · see citing works
Diagnosis and characteristics of syncope in older patients referred to geriatric departments
Ungar, A., Mussi, C., Del Rosso, A., Noro, G., Abete, P., Ghirelli, L., Cellai, T., Landi, A., Salvioli, G., Rengo, F., et al. (2006) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2006.00891.x · Cited by 127 · see citing works
The economic burden of unrecognized vasodepressor syncope
Calkins, H. G., Byrne, M., El-Atassi, R., Kalbfleisch, S., Langberg, J. J., & Morady, F. (1993) · The American Journal of Medicine · doi:10.1016/0002-9343(93)90329-n · Cited by 100 · see citing works
Vasovagal Syncope in the Older Patient
Tan, M. P., & Parry, S. W. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2007.11.025 · Cited by 92 · see citing works
Barón‐Esquivias, G., Martínez Alday, J., Martı́n, A., Moya‐Mitjans, À., García–Civera, R., López Chicharro, M. P., Martín-Méndez, M., del Arco, C., & Laguna, P. (2010) · Hispana · Cited by 81 · see citing works
Clinical spectrum of neurally mediated reflex syncopes
Alboni, P. (2003) · EP Europace · doi:10.1016/j.eupc.2003.09.003 · Cited by 75 · see citing works
Clinical characteristics of patients with vasovagal reactions presenting as unexplained syncope
Graham, L. (2001) · EP Europace · doi:10.1053/eupc.2001.0155 · Cited by 71 · see citing works
Kurbaan, A. S., Franzén, A.-C., Bowker, T. J., Williams, T. R., Kaddoura, S., PETERSEN, M. E. V., & Sutton, R. (1999) · The American Journal of Cardiology · doi:10.1016/s0002-9149(99)00413-0 · Cited by 57 · see citing works
Romme, J. J. C. M., van Dijk, N., Boer, K. R., Bossuyt, P. M. M., Wieling, W., & Reitsma, J. B. (2009) · European Heart Journal · doi:10.1093/eurheartj/ehp314 · Cited by 55 · see citing works
Methodology of head-up tilt testing potentiated with sublingual nitroglycerin in unexplained syncope
Rosso, A. D., Bartoletti, A., Bartoli, P., Ungar, A., Bonechi, F., Maioli, M., & Ieri, A. (2000) · The American Journal of Cardiology · doi:10.1016/s0002-9149(99)00919-4 · Cited by 51 · see citing works
Wiener Klinische Wochenschrift
(1966) · JAMA · doi:10.1001/jama.1966.03100220145096 · Cited by 51 · see citing works
Effects of age on outcome of tilt-table testing
Bloomfield, D. M., Maurer, M. S., & Bigger, J. T. (1999) · The American Journal of Cardiology · doi:10.1016/s0002-9149(99)00014-4 · Cited by 50 · see citing works
Duncan, G. W., Tan, M. P., Newton, J. L., Reeve, P., & Parry, S. W. (2010) · Age and Ageing · doi:10.1093/ageing/afq039 · Cited by 49 · see citing works
Tilt testing for syncope: a reappraisal.
Sheldon, R. S. (2005) · PubMed · Cited by 46 · see citing works
Admission for syncope: evaluation, cost and prognosis.
Schillinger, M., Domanovits, H., Müllner, M., Herkner, H., & Laggner, A. N. (2000) · PubMed · Cited by 32 · see citing works
Verbal fluency in senile dementia: an analysis of search and knowledge
Diesfeldt, H. (1985) · Archives of Gerontology and Geriatrics · doi:10.1016/0167-4943(85)90005-6 · Cited by 29 · see citing works
Kumar, N., V (2000) · Age and Ageing · doi:10.1093/ageing/29.5.419 · Cited by 24 · see citing works
Morillo, C. A. (2005) · European Heart Journal · doi:10.1093/eurheartj/ehi663 · Cited by 12 · see citing works
Self-citationRECURRENT SYNCOPE IN ELDERLY PATIENTS AND TILT TEST TABLE OUTCOME: THE ROLE OF COMORBIDITIES
Vetta, F., RONZONI, S., Costarella, M., Donadio, C., Battista, L., Renzulli, G., Gentile, G., & Zuccaro, S. M. (2009) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2009.09.034 · Cited by 11 · see citing works
Registry on the evaluation of syncope assessment strategy in the emergency room (RESASTER study)
Baranchuk, A. M., Morgan, S., Krahn, A. D., Bentley, C., Ribas, S., Guzmán, J. C., Healey, J. S., Nair, G. M., Connolly, S. J., & Morillo, C. A. (2005) · Heart Rhythm · doi:10.1016/j.hrthm.2005.02.835 · Cited by 10 · see citing works
Self-citationSagristà-Sauleda, J., Romero, B. A., Permanyer‐Miralda, G., Moya‐Mitjans, À., Gelabert, T. R., Girbau, L. M., & Soler‐Soler, J. (1999) · EP Europace · doi:10.1053/eupc.1998.0015 · Cited by 9 · see citing works
Neurokardiogene Synkopen bei Herzschrittmachertherapie
Keim, M., Momper, R., Heck, K. F., et al. (2008) · DMW - Deutsche Medizinische Wochenschrift · doi:10.1055/s-2007-1024457 · Cited by 6 · see citing works
Transient loss of consciousness: an ongoing challenge
Vardas, P. E., & SIMANTIRAKIS, E. N. (2010) · EP Europace · doi:10.1093/europace/euq139 · Cited by 5 · see citing works
&NA;, &. (1995) · Current Opinion in Cardiology · doi:10.1097/00001573-199511000-00020 · Cited by 3 · see citing works
27 Long-term results of VVI and DDD pacing modes in patients with sick sinus syndrome
z, B. C., İnce, O., Yazıcıoğlu, N., et al. (2005) · EP Europace · doi:10.1016/eupace/7.supplement_1.6 · Cited by 1 · see citing works
Flagged first, then by citations
Research works printed but not linked: 2
- [29]29. Morillo CA. Evidence-based common sense: the role of clinical history for the diagnosis of vasovagal syncope. Eur Heart J 2006;27:253 -4.
- [31]31. Keim MW, Momper R, Heck KF, Braun B, Hust MH. Neurocardiogenic syn- cope's in patients with implanted pacemakers. Dtsch Med Wochenschr 1999; 124:953-7.
Cited by
Sorted by citations
Sheldon, R. S., Grubb, B. P., Olshansky, B., Shen, W.-K., Calkins, H., Brignole, M., Raj, S. R., Krahn, A. D., Morillo, C. A., Stewart, J. M., et al. (2015) · Heart Rhythm · doi:10.1016/j.hrthm.2015.03.029 · Cited by 1,013 · see citing works
“Generally, attempts at validation have not been conducted with patients as rigorously defined as in the derivation studies.(94,95) Although these scores report overall high degrees of accuracy, they likely require revision and validation in larger populations.”
BackgroundSelf-citation2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.03.004 · Cited by 484 · see citing works
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.03.003 · Cited by 327 · see citing works
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.03.002 · Cited by 155 · see citing works
- Authors
- Exposito, V., Guzman, J. C., Orava, M., Armaganijan, L., & Morillo, C. A.
- Affiliations
- McMaster University (CA)
- Corresponding author
- Morillo, C. A.
- Venue
- Europace
- Publisher
- Oxford University Press (OUP)
- Published
- 2013-03-10
- Volume
- 15
- Issue
- 8
- Pages
- 1210-1214
- ISSN
- 1099-5129 (ISSN-L)
- 1532-2092
- OpenAlex
- W2111030179
- Semantic Scholar
- 01aa8d70b800cfbe6a8c21d85bc4cd44921d8dc2
- Cited by
- 27
- References
- 45
- Citations by year
- 2025: 1 · 2023: 4 · 2022: 1 · 2021: 2 · 2020: 2 · 2017: 7 · 2016: 2 · 2015: 5 · 2014: 2 · 2013: 1
- FWCI
- 3.29
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- EP Europace (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Life Sciences › Neuroscience › Neurology › Vestibular and auditory disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- vasovagal syncope, syncope, elderly patients, head-up tilt, diagnostic accuracy, sensitivity and specificity, cardiovascular disease
- MeSH terms
- Aged, Aged, 80 and over, Female, Nitroglycerin, Humans, Male, Middle Aged, Ontario, Risk Factors, Sensitivity and Specificity, Severity of Illness Index, Vasodilator Agents, Reproducibility of Results, Prevalence, Tilt-Table Test, Syncope, Vasovagal
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