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.
Syncope is a common, potentially serious condition accounting for many hospital admissions.
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.
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 ≥300 pg/ml (odds ratio [OR]: 7.3), positive fecal occult blood (OR: 13.2), hemoglobin ≤90 g/l (OR: 6.7), oxygen saturation ≤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%).
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.