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Volume , . : April Annals of Emergency Medicine 431Policy statements and clinical policies are the official policies of the American College of EmergencyPhysicians and, as such, are not subject to the same peer review process as articles appearing in the printjournal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefsof Annals of Emergency Medicine and its editors.

96-0644/$-see front matterpyright 2007 by the American College of Emergency Physicians.:10.1016/j.annemergmed.2007.02.001

[Ann Emerg Med. 2007;49:431-444.]

TRODUCTIONSyncope is a symptom complex that is composed of a briefs of consciousness associated with an inability to maintainstural tone that spontaneously and completely resolvesthout medical intervention. It is distinct from vertigo,zures, coma, and states of altered consciousness. Syncope is a

common presentation to the emergency department (ED) thataccounts for 1% to 1.5% of ED annual visits and up to 6% ofhospital admissions.1,2 The ED evaluation of patients withsyncope may be problematic for several reasons. Accuratehistorical information is often lacking or there may beconflicting historical information from observers. Furthermore,patients are often asymptomatic when they arrive in the ED andmay have no recall of the event.2007)att W. Decker, MD (Co-Chair 2006-2007)borah B. Diercks, MDnathan A. Edlow, MDncis M. Fesmire, MDeven A. Godwin, MDrid A. Hahn, MDhn M. Howell, MDStephen Huff, MDomas W. Lukens, MD, PhDnna L. Mason, RN, MS, CEN (ENA Representative2004-2006)thony M. Napoli, MD (EMRA Representative 2004-2006)Richmann, RN, BS, MA(c), CEN (ENA Representative2006-2007)ott M. Silvers, MDward P. Sloan, MD, MPHbert L. Wears, MD, MS (Methodologist)lly E. W. Thiessen, MD (EMRA Representative 2007)ephen J. Wolf, MDerri D. Hobgood, MD (Board Liaison 2004-2006)onda R. Whitson, RHIA, Staff Liaison, Clinical PoliciesCommittee and Subcommittees

proved by the ACEP Board, January 19, 2007pported by the Emergency Nurses Association,February 21, 2007ne Peeters, MD (Dutch Society of Emergency Physicians)S. Jagoda, MD

bers of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee):

S. Jagoda, MD (Chair 2003-2006; Co-Chair 2006- Devorah Nazarian, MDmes V. Quinn, MD, MSdrew D. Perron, MDlinical Policy: Critical Issues inof Adult Patients Presenting to

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m the American College of Emergency Physicians ClinicaStephen Huff, MD (Subcommittee Chair)e Evaluation and Managementhe Emergency Departmentope

icies Subcommittee (Writing Committee) on Syncope:

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Clinical Policy

43the precipitant of syncope. Concerns that well-appearingtients are at risk for sudden death often fuel extensive clinicalluations or hospital admissions because the large differentialgnosis includes some processes that may be life-threatening.any studies have demonstrated the low yield of nondirectedgnostic testing.3-6 From the available literature, it is unclearether admitting asymptomatic syncope patients forservation and inpatient evaluation affects patient outcome.ditionally, it is estimated that more than $2 billion a year isnt in the United States on hospitalization of patients withcope.7 An analysis of the 2001 American College ofergency Physicians (ACEP) clinical policy on syncope foundt by applying the Level B recommendations, all patients withdiac causes of syncope were identified, and the admission rateuld be reduced from 57.5% to 28.5%.8 These facts must leada reassessment of the role of the emergency physician inluation of the patient presenting with syncope.The emergency physician must still identify those relativelypatients with life-threatening processes (eg, dysrhythmias,

lmonary embolism, aortic dissection, subarachnoidmorrhage, acute coronary syndromes) and other patients whoy benefit from intervention (eg, patients with bradycardia,dication-induced orthostatic hypotension). Frequently,wever, the ED evaluation of a patient presenting withcope does not reveal a clear etiology. The emergencyysician must then determine which of these patients requirether diagnostic evaluation and monitoring and in whatting that should occur. The role of the emergency physicianevaluating the patient with syncope has moved from effortsdetermine a specific diagnosis of syncope type to that of riskatification, similar to the process of chest pain evaluation.Symptoms and complaints associated with syncope should bely evaluated. A careful history should be obtained,nsidering other associated symptoms, whether cardiac,urologic, abdominal, or respiratory, because it may lead to agnosis of an underlying medical condition such as an acuteronary event, aortic dissection, pulmonary embolism, seizure,opic pregnancy, or gastrointestinal hemorrhage.This document does not attempt to outline the evaluation oftients presenting with syncope associated with specificgnoses but rather focuses on assisting the emergencyysician in addressing 3 critical questions:What history and physical examination data help to risk-stratify patients with syncope?What diagnostic testing data help to risk-stratify patientswith syncope?Who should be admitted after an episode of syncope ofunclear cause?This policy is an update of the 2001 ACEP clinical policy oncope.9 Other professional societies have developed guidelinesevaluation of syncope but this policy is designed to reflectommendations focused on the practice of emegencydicine.10,112 Annals of Emergency MedicineThis clinical policy was created after careful review andtical analysis of the medical literature. MEDLINE searchesarticles published between March 1998 and May 2005 wererformed using a combination of key words, includingncope and variations of risk, risk stratification,mission, outcomes, emergency department,rognosis, differential diagnosis, physical examination,d diagnostic evaluation. Searches were limited to English-guage sources. Additional articles were reviewed from theliographies of studies cited. Subcommittee members alsoplied articles from their own knowledge and files.The reasons for developing clinical policies in emergencydicine and the approaches used in their development haveen enumerated.12 This policy is a product of the ACEPnical policy development process and is based on the existingrature; where literature was not available, consensus ofergency physicians was used. Expert review comments wereeived from individual emergency physicians, individualmbers of the American College of Cardiology, members ofEPs Observation Section, Geriatric Section, and Qualityd Performance Committee. Their responses were used tother refine and enhance this policy. Clinical policies areeduled for revision every 3 years; however, interim reviewsconducted when technology or the practice environment

anges significantly.All articles used in the formulation of this clinical policy wereded by at least 2 subcommittee members for strength ofdence and classified by the subcommittee members into 3sses of evidence on the basis of the design of the study, withsign 1 representing the strongest evidence and design 3resenting the weakest evidence for therapeutic, diagnostic,d prognostic clinical reports respectively (Appendix A).ticles were then graded on 6 dimensions thought to be mostevant to the development of a clinical guideline: blindedsus nonblinded outcome assessment, blinded or randomizedocation, direct or indirect outcome measures (reliability andidity), biases (eg, selection, detection, transfer), externalidity (ie, generalizability), and sufficient sample size. Articleseived a final grade (Class I, II, III) on the basis of adetermined formula taking into account design and qualitystudy (Appendix B). Articles with fatal flaws were given an grade and not used in formulating recommendations in thislicy. Evidence grading was done with respect to the specificta being extracted, and the specific critical question beingiewed. Thus, the level of evidence for any one study may varyording to the question, and it is possible for a single article toeive different levels of grading as different critical questionsanswered. Question-specific level of evidence grading may bend in the Evidentiary Table included at the end of thislicy.Clinical findings and strength of recommendations regardingtient management were then made according to the followingteria:Volume , . : April

Level A recommendations. Generally accepted principles forpacerovstu

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Votient management that reflect a high degree of clinicaltainty (ie, based on strength of evidence Class I orerwhelming evidence from strength of evidence Class IIdies that directly address all of the issues).Level B recommendations. Recommendations for patientnagement that may identify a particular strategy or range ofnagement strategies that reflect moderate clinical certainty, based on strength of evidence Class II studies that directlydress the issue, decision analysis that directly addresses theue, or strong consensus of strength of evidence Class IIIdies).Level C recommendations. Other strategies for patientnagement that are based on preliminary, inconclusive, ornflicting evidence, or in the absence of any publishedrature, based on panel consensus.There are certain circumstances in which theommendations stemming from a body of evidence shouldt be rated as highly as the individual studies on which theybased. Factors such as heterogeneity of results, uncertainty

out effect magnitude and consequences, strength of priorliefs, and publication bias, among others, might lead to such awngrading of recommendations.This policy is not intended to be a complete manual onevaluation and management of adult patients withcope but rather a focused look at critical issues that haverticular relevance to the current practice of emergencydicine.It is the goal of the Clinical Policies Committee tovide an evidence-based recommendation when thedical literature provides enough quality information toswer a critical question. When the medical literature doest contain enough quality information to answer a criticalestion, the members of the Clinical Policies Committeelieve that it is equally important to alert emergencyysicians to this fact.Recommendations offered in this policy are not intendedrepresent the only diagnostic and management optionst the emergency physician should consider. ACEP clearlyognizes the importance of the individual physiciansgment. Rather, this guideline defines for the physicianse strategies for which medical literature exists to provideport for answers to the crucial questions addressed in thislicy.Scope of Application. This guideline is intended forysicians working in hospital-based EDs.Inclusion Criteria. This guideline is intended for adulttients presenting to the ED with syncope.Exclusion Criteria. This guideline is not intended forildren or for patients in whom the episode of syncope isught to be secondary to another disease process. Amongclinical conditions specifically excluded are patients with

zures, chest pain, headache, abdominal pain, dyspnea,morrhage, hypotension, or a new neurologic deficit.lume , . : April What history and physical examination data help to risk-atify patients with syncope?

Level A recommendations. Use history or physicalmination findings consistent with heart failure to helpntify patients at higher risk of an adverse outcome.Level B recommendations.Consider older age, structural heart disease, or a history ofcoronary artery disease as risk factors for adverse outcome.Consider younger patients with syncope that isnonexertional, without history or signs of cardiovasculardisease, a family history of sudden death, and withoutcomorbidities to be at low risk of adverse events.Level C recommendations. None specified.

The traditional approach of focusing on establishing anology of syncope in the ED is often of limited utility.ultiple studies have demonstrated a diagnostic rate of only% to 50% in the initial evaluation of the syncopetient.1,13,14 Even in subspecialty studies with patientsdergoing extensive diagnostic evaluations, 15% to 30% oftients remain without a definitive cause.15-18 Review of thecope literature reveals that because of the lack of a criterionndard, the final diagnosis given to a syncope patient isficult to validate and subject to variability.Few studies have directly evaluated risk stratification ofcope patients in the ED. In a Class I study, Martin et al5

died 252 syncope patients to develop a risk classificationtem and then tested the system in a validation cohort of 374tients. Predictors of arrhythmia or 1-year mortality in theidation cohort were found to be: (1) abnormal ECG result,history of ventricular arrhythmia, (3) history of congestive

art failure, or (4) age more than 45 years. The event rateinically significant arrhythmia or death) at 1 year in theidation cohort ranged from 0% for those with none of the 4k factors to 27% for those with 3 or 4 risk factors. In ailarly designed Class I study from Italy, Colivicchi et al19

rived risk factors for 1-year mortality (not arrhythmias) in0 patients and then validated them on 328 patients andnd an abnormal ECG result, a history of cardiovascularease, lack of prodrome, and age older than 65 years to predictdeaths in the 2 cohorts. These studies have determined that, abnormal ECG result, lack of a prodrome, a history ofdiovascular disease, especially ventricular arrhythmia, andart failure all appear to have predictive value in assessing 1-r risk of adverse outcomes in patients with syncope.A Class I study by Quinn et al,2 the San Francisco Syncopedy, examined short-term serious events in 684 ED patientssenting with syncope. Recursive partitioning techniquesntified the following characteristics associated with a higherelihood of an adverse event within 7 days of ED presentation:normal ECG result, shortness of breath, systolic bloodssure less than 90 mm Hg after arrival in the ED, hematocritel less than 30%, and congestive heart failure by history ormination. This derivation set has now been prospectivelyAnnals of Emergency Medicine 433

validated.20A prospective Class III study by Sarasin et al21 alsofoufaiexp

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Clinical Policy

43nd that an abnormal ECG result, history of congestive heartlure, and age more than 65 years were all risk factors foreriencing a serious arrhythmia.Little literature exists to guide the clinician in cases ofrtional syncope in young patients (age 35 years). This is ancommon occurrence, usually with a very different etiologyn syncope in an older patient. Possible etiologies includepertrophic cardiomyopathy, coronary artery abnormalities,nduction abnormalities (long QT, preexcitation syndromes),d arrythmogenic cellular dysplasias. Cardiology consultationy be considered either as an inpatient or outpatient.

story and Physical Examination DataHistory and physical examination are the defining factors incope risk stratification. Often the patient may not haveurate recall of the event; thus, eyewitness accounts, are anportant part of the history, which includes estimation ofration of loss of consciousness and evidence of seizureivity. Mild, brief, tonic-clonic activity may commonlyompany syncope of any etiology (convulsive syncope).itnesses also may report falls or other trauma during theisode. Postsyncopal history, also best obtained fromwitnesses, includes duration of confusion or lethargy afterepisode or evidence of focal neurologic deficits. After an

isode of syncope, patients may briefly appear disoriented ornfused, but this resolves within moments and is often shortern the postictal period associated with generalized seizures.sent or brief prodrome (less than 5 seconds) may be presentth dysrrhythmias, whereas neurally mediated syncopenonyms include neurocardiogenic syncope and vasovagalcope) may be characterized by longer prodromes andociated nausea or vomiting. Obvious precipitating events oress with a consistent history may be sufficient to diagnoseurally mediated syncope, which is important because thegnosis of neurally mediated syncope is consistently associatedth a good prognosis.22 However, it is problematic thatdromal symptoms are subjective, and agreement on thesence of vagal symptoms and the eventual diagnosis isonsistent among physicians.2 Syncope that occurs while thetient is seated or reclining is more likely to have a cardiacology,23 whereas syncope that occurs within 2 minutes ofnding may suggest orthostatic hypotension.24,25

Medications and drug interactions may cause syncope. Manygs prolong the QT interval and are associated with life-eatening dysrhythmias. Vasoactive drugs such astihypertensive agents, vasodilators used for angina, and thosed for erectile dysfunction may lead to syncope. In one study,tihypertensive agents, other cardiovascular drugs, diuretics,d central nervous system agents were most frequently cited asause of syncope. Drug-related syncope was especiallymmon in elderly patients taking multiple medications.26

Though less well established in the literature, a family historypremature sudden cardiac death should alert the clinician topossibility of serious congenital conduction abnormalities,4 Annals of Emergency Medicineugada syndrome.The demographic variables of age, sex, and race are potentialk factors for cardiovascular disease. Epidemiologic and cohortdies have confirmed the importance of age,3,5,22 though ofurse age alone is a marker for increased mortality. Althoughreasing age is accompanied by an increased risk of poortcome, there is no single age cutoff but rather a continuum ofdually increasing risk.Cardiovascular diagnoses and older age do increase the risksudden death in patients with syncope. In a prospectivehort study, in patients older than 60 years, those with adiovascular diagnosis regardless of age had an increase inden death within 2 years.30 Two Class II studies founddiovascular risk to be the only predictor of 1-year mortalityd also found that cardiovascular risk, not syncope, was thest predictor of mortality and cardiovascular events.31,32

cording to Class I and Class II studies, patients younger thanyears, in the absence of other symptoms or examinationdings, tend to be of lower risk, whereas older patients are atater risk for adverse outcomes. There is no discrete cutoff ageassessing age-related risk, and the ability to make any firm-based recommendation about risk stratification isnfounded by the arbitrary choice of age thresholds in differentdies. Patients with a history of poor left ventricular function,ich appears to be best predicted by a diagnosis of heartlure, are consistently at greater risk of sudden death in almostry study assessing risk,2,5,19,21 which is not just due to thet that a history of heart failure alone has a poor prognosis.ncope in the patient with heart failure is a poor prognosticn. Middlekauff et al33 showed in a Class II study that even iftients with heart failure are diagnosed with a noncardiacology for their syncope, these patients appeared to be at risksudden death. Exertional syncope raises special concernsout structural heart lesions producing fixed cardiac output.Vital signs. Loss of consciousness with syncope is transient,d the hypoperfusion or hypotension usually is transient asll. Persistent hypotension is concerning and should suggestpossiblity of another disease process. Tachycardia and

potension may represent ongoing hemodynamic instability orlume depletion, and a cause for persistent hypotension (sepsis,morrhage, cardiac failure) should be sought.Orthostatic hypotension is usually defined as a decrease intolic blood pressure with standing of 20 mm Hg or greater.is finding may identify some patients with syncope related tolume depletion, autonomic insufficiency, or medications.currence of symptoms such as light-headedness or evencope on standing is more significant than any numericange in blood pressure. Orthostatic hypotension is commonpatients with syncope of unknown etiology, as well as intients with other documented diagnoses such as cardiacease, and is detected in most patients within 2 minutes afternding. This finding is also present in up to 40% ofmptomatic patients older than 70 years, and 23% of thoseVolume , . : April

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Vopotension as a cause of syncope should be symptom-relatedd a diagnosis of exclusion in otherwise low-risk patients, withrealization that many high-risk patients will havehostasis.34

Cardiopulmonary. Physical examination findings ofngestive heart failure are indicators of high risk of suddenath or early mortality after syncope, as shown in a Class Idy.2 Murmurs indicative of valvular heart disease or outflowstruction should prompt further evaluation for structuralart disease.Head and face. Tongue biting, particularly if it is lateral,s a high specificity for convulsive seizures. Because of lowsitivity, absence of tongue bites has no diagnosticnificance.35 Head trauma resulting from syncope is notociated with any particular type of syncope or short-termtcome,2 although syncope and resultant head injury haveen associated with 1-year death.19

Abdominal. Abdominal pain or tenderness associated withcope should be investigated. It may be a marker ofnificant pathology or hemorrhage. Rectal examination withservation and testing for bleeding is recommended iftrointestinal hemorrhage is suspected.

What diagnostic testing data help to risk-stratify patientsth syncope?

Level A recommendations. Obtain a standard 12-lead ECGpatients with syncope.Level B recommendations. None specified.Level C recommendations. Laboratory testing and advancedestigative testing such as echocardiography or cranial CTnning need not be routinely performed unless guided bycific findings in the history or physical examination.

agnostic Testing DataIn patients for whom a diagnosis of syncope is established,tory and physical examination identify the cause in thejority of patients in which an etiology will be established.e yield of the ECG in finding a cause is low (less than),3,4,36,37 but the test is noninvasive and relativelyxpensive and can occasionally pick up potentially life-eatening conditions such as preexcitation syndromes,longed QT syndromes, or Brugada syndrome in otherwisealthy-appearing young adults.27,28 A patient with a normalG result has a low likelihood of dysrhythmias as a cause ofcope.2,21,38 The definitions of an abnormal ECG vary fromdy to study and within specialty guidelines. One studyfined an abnormal ECG result as any nonsinus rhythm or anG with any new changes compared with a previous ECG andnd it the most important predictor of serious outcomes.2

other study found the presence of an abnormal ECGfined as any abnormality of rhythm or conduction,tricular hypertrophy, or evidence of previous myocardialarction but excluding nonspecific ST-segment and T-wavelume , . : April thin 1 year after the syncopal episode.Cardiac monitoring. Continuous cardiac monitoring in theoccasionally detects an arrhythmia not evident on a single

-lead tracing. A strong suspicion of arrhythmias may promptatient or ambulatory monitoring. For most patients,nitoring longer than 24 hours is not likely to increase thetection of significant arrhythmias. One study found 4 factorst identified patients likely to have an abnormality withlonged monitoring of up to 72 hours: (1) age older than 65rs, (2) male sex, (3) history of heart disease, and (4) nonsinusthm on initial ECG. However, none of the patients withhythmias detected in the second and third 24-hour periodsre symptomatic.39

Laboratory testing. In an evaluation of syncope, laboratoryts rarely yield any diagnostically useful information, and theirtine use is not recommended.3,36,37 However, in anselected group of patients presenting to the ED with syncopem any cause, Quinn et al2 found hematocrit level less than% to be a useful predictor of adverse events.Advanced tests and imaging. There is no evidence togest that routine screening of syncope patients with advancedaging (such as CT), testing such as functional cardiacocardiography, or electrophysiologic testing is indicated. In aass II study on echocardiography and syncope, Sarasin et al40

nd that the only added clinically useful information was inse patients with a history of cardiac disease, an abnormalG result, or when aortic stenosis was suspected. The use ofvanced testing must be guided by the patients history andysical examination results, shaping the physicians overallpression of likelihood that any of the rare, life-threateningnditions that can present with syncope might exist.

Who should be admitted after an episode of syncope ofclear cause?

Level A recommendations. None specified.Level B recommendations.Admit patients with syncope and evidence of heart failure orstructural heart disease.Admit patients with syncope and other factors that lead tostratification as high-risk for adverse outcome (Figure).Level C recommendations. None specified.

The primary reason for admitting patients with syncope to anatient unit, observation unit, or other monitored area shouldthat the physicians risk assessment indicates that a patienty be at risk for significant dysrrhythmia or sudden death andt observation might detect that event and enable anervention. Problematic is the definition of short-termtcome, which is subjective and not clearly defined. Whichtients will benefit from a 24- to 48-hour hospital admission orservation unit admission is not adequately described in thedical literature, nor has the value of admission in preventingater adverse outcome been demonstrated. Endpoints fortients followed up after an episode of syncope are typicallyAnnals of Emergency Medicine 435

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43orted at intervals of 6 months to 1 year or even longer. OnlySan Francisco Syncope Rule, which used an endpoint of 7

ys, has evaluated short-term risk of patients discharged fromED. Other studies of ED patients have patient numbers that too small for firm conclusions.41 The most rational approachadmission is to understand the specific risks for patients asted in critical question 1, and make the admission decision inht of available literature. High-risk patients require hospitalmission. However, one should also realize that the decision tomit patients often takes into consideration other symptoms,er medical problems, and social factors. Admission may alsoinitiated for additional testing and consultation or forticipated therapy.

ture DirectionsA small number of studies have explored a clinical decisionobservation unit, with testing or consultation as anernative to inpatient admission in patients stratified as neitherh-risk nor low-risk for adverse outcomes (ie, intermediate-k patients). Further studies are needed to identify distinctgroups that might benefit from this strategy.42 Thetinction between ED evaluation and admission is blurringth the availability of additional diagnostic resources, theportunity for longer observation periods, and the reality oflonged ED stays.

FERENCESBlanc JJ, LHer C, Touiza A, et al. Prospective evaluation andoutcome of patients admitted for syncope over a 1 year period.Eur Heart J. 2002;23:815-820.Quinn JV, Stiell IG, McDermott DA, et al. Derivation of the SanFrancisco syncope rule to predict patients with short-term seriousoutcomes. Ann Emerg Med. 2004;43:224-232.Kapoor WN, Karpf M, Wieand S, et al. A prospective evaluationand follow-up of patients with syncope. N Engl J Med. 1983;309:197-204.Day SC, Cook EF, Funkenstein H, et al. Evaluation and outcomeof emergency room patients with transient loss of consciousness.Am J Med. 1982;73:15-23.

Abnormal ECGHct 30 (if obtained)History or presence of heart failure, coronary arterydisease, or structural heart disease

*Different studies use different ages as threshold fordecisionmaking. Age is likely a continuous variable thatreflects the cardiovascular health of the individual ratherthan an arbitrary value.

ECG abnormalities, including acute ischemia,dysrhythmias, or significant conduction abnormalities.

ure. Factors that lead to stratification as high-risk forverse outcome.6 Annals of Emergency MedicinePires LA, Ganji JR, Jarandila R, et al. Diagnostic patterns andtemporal trends in the evaluation of adult patients hospitalizedwith syncope. Arch Intern Med. 2001;161:1889-1895.Sun BC, Emond JA, Carmargo CA. Direct medical costs ofsyncope-related hospitalizations in the United States. Am JCardiol. 2005;95:668-671.Elesber AA, Decker WW, Smars PA, et al. Impact of theapplication of the American College of Emergency Physiciansrecommendations for the admission of patients with syncope ona retrospectively studied population presenting to the emergencydepartment. Am Heart J. 2005;149:826-831.American College of Emergency Physicians. Clinical policy: criticalissues in the evaluation and management of patients presentingwith syncope. Ann Emerg Med. 2001;37:771-776.

. Strickberger SA, Benson W, Biaggioni I, et al. AHA/ACCF scientificstatement on the evaluation of syncope. J Am Coll Cardiol. 2006;12:473-484.

. Brignole M, Alboni P, Benditt DG, et al. Guidelines onmanagement (diagnosis and treatment) of syncope-update 2004executive summary. Eur Heart J. 2004;25:2054-2072.

. Schriger DL, Cantrill SV, Greene CS. The origins, benefits, harms,and implications of emergency medicine clinical policies. AnnEmerg Med. 1993;22:597-602.

. Crane SD. Risk stratification of patients with syncope in anaccident and emergency department. Emerg Med J. 2002;19:23-27.

. Kapoor WN, Karpf M, Maher Y, et al. Syncope of unknown origin.JAMA. 1982;247:2687-2691.

. Farwell DJ, Freemantle N, Sulke AN. Use of implantable looprecorders in the diagnosis and management of syncope. EurHeart J. 2004;25:1257-1263.

. Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of historyin patients with syncope with or without heart disease. J Am CollCardiol. 2001;37:1921-1928.

. Ammirati F, Colivicchi F, Santini M. Diagnosing syncope in clinicalpractice. Implementation of a simplified diagnostic algorithm in amulticentre prospective trial the OESIL 2 Study (OsservatorioEpidemiologico della Sincope nel Lazio). Eur Heart J. 2000;21:935-940.

. Sarasin FP, Louis-Simonet M, Carballo D, et al. Prospectiveevaluation of patients with syncope: a population-based study.Am J Med. 2001;111:177-184.

. Colivicchi F, Ammirati F, Melina D, et al. Development andprospective validation of a risk stratification system for patientswith syncope in the emergency department: the OESIL risk score.Eur Heart J. 2003;24:811-819.

. Quinn J, McDermott D, Stiell I, et al. Prospective validation of theSan Francisco syncope rule to predict patients with seriousoutcomes. Ann Emerg Med. 2006;47:448-454.

. Sarasin FP, Hanusa BH, Perneger T, et al. A risk score to predictarrhythmias in patients with unexplained syncope. Acad EmergMed. 2003;10:1312-1317.

. Soteriades ES, Evans JC, Larson MG, et al. Incidence andprognosis of syncope. N Engl J Med. 2002;347:878-885.

. Calkins H, Shyr Y, Frumin H, et al. The value of the clinical historyin the differentiation of syncope due to ventricular tachycardia,atrioventricular block, and neurocardiogenic syncope. Am J Med.1995;98:365-373.

. Atkins D, Hanusa B, Sefcik T, et al. Syncope and orthostatichypotension. Am J Med. 1990;91:179-185.

. Graham LA, Kenny RA. Clinical characteristics of patients withvasovagal reactions presenting as unexplained syncope.Europace. 2001;3:141-146.Volume , . : April

26. Hanlon JT, Linzer M, MacMillan JP, et al. Syncope andpresyncope associated with probable adverse drug reactions.Arch Intern Med. 1990;150:2309-2312.

27. Jones RA, Swor RA. A near-fatal case of long QT syndrome in ateenaged male. Prehospital Emerg Care. 2001;5:296-299.

28. Juang J-M, Huang SKS. Brugada syndrome an under-recognizedelectrical disease in patients with sudden cardiac death.Cardiology. 2004;101:157-169.

29. Mok N-S, Chan N-Y. Brugada syndrome presenting with sustainedmonomorphic ventricular tachycardia. Int J Cardiol. 2004;97:307-309.

30. Kapoor W, Snustad D, Peterson J, et al. Syncope in the elderly.Am J Med. 1986;80:419-428.

31. Oh JH, Hanusa BH, Kapoor WN. Do symptoms predict cardiacarrhythmias and mortality in patients with syncope? Arch InternMed. 1999;159:375-380.

32. Kapoor WN, Hanusa BH. Is syncope a risk factor for pooroutcomes? comparison of patients with and without syncope.Am J Med. 1996;100:647-655.

33. Middlekauff HR, Stevenson WG, Stevenson LW, et al. Syncopein advanced heart failure: high risk of sudden death regardlessof origin of syncope. J Am Coll Cardiol. 1993;21:110-116.

34. Sarasin FP, Louis-Simonet M, Carballo D, et al. Prevalence oforthostatic hypotension among patients presenting withsyncope in the ED. Am J Emerg Med. 2002;20:497-501.

35. Benbadis SR, Wolgamuth BR, Goren H, et al. Value of tonguebiting in the diagnosis of seizures. Arch Intern Med. 1995;155:2346-2349.

36. Eagle KA, Black HR. The impact of diagnostic tests inevaluating patients with syncope. Yale J Biol Med. 1983;56:1-8.

37. Martin GJ, Adams SL, Martin HG, et al. Prospective evaluation ofsyncope. Ann Emerg Med. 1984;13:499-504.

38. Kapoor WN, Peterson J, Wieand HS, et al. Diagnostic andprognostic implications of recurrences in patients with syncope.Am J Med. 1987;83:700-707.

39. Bass EB, Curtiss EI, Arena VC, et al. The duration of Holtermonitoring in patients with syncope. Is 24 hours enough? ArchIntern Med. 1990;150:1073-1078.

40. Sarasin FP, Junod A-F, Carballo D, et al. Role of echocardiographyin the evaluation of syncope: a prospective study. Heart. 2002;88:363-367.

41. Morag RM, Murdock LF, Khan ZA, et al. Do patients with anegative emergency department evaluation for syncope requireadmission? J Emerg Med. 2004;27:339-343.

42. Shen WK, Decker WW, Smars PA, et al. Syncope evaluation inthe emergency department study (SEEDS): a multidisciplinaryapproach to syncope management. Circulation. 2004;110:3636-3645.

Clinical Policy

Volume , . : April Annals of Emergency Medicine 437

Eviden

tiaryTa

ble.

Cl

43s

inical PolicyStudy

Yea

rDesign

Interven

tion

(s)/

Test(s)/Mod

ality

Outco

meMea

sure/

Criterion

Stand

ard

Results

Limitations/Com

men

tsClas

Blanc

et al

1

2002

Pros

pective co

hort,

obse

rvationa

l,with

retros

pective

review

ofch

arts

Rev

iew

ofallp

atients(37,475)

pres

entin

gto

theED

from

June

1999to

June

2000;

with

sync

ope:

454ha

dde

finite

sync

ope

454(1.2%)werediag

nose

das

having

sync

ope;

for

296pa

tients,

itwas

the

first

episod

e;169were

disc

harged

from

theED

;285weread

mitted

;in

76%

ofpa

tients,

adisc

hargediag

nosiswas

repo

rted

butev

alua

tion

was

inad

equa

teto

explainasync

opal

episod

ein

16%

Synco

peis

afreq

uent

symptom

,bu

tits

caus

eoftenremains

unkn

ownpa

rtly

beca

useof

inad

equa

teman

agem

ent

Study

look

edat

theev

alua

tion

anddiag

nostic

finding

sof

patie

ntsad

mitted

toa

hosp

italinFran

ce;de

finition

ofsync

openo

tclea

rin

patie

ntno

tes

III

Quinn

et al

2

2004

Pros

pective co

hort

stud

yPh

ysicians

pros

pectively

completed

astructured

data

form

whe

nev

alua

ting

patie

ntswith

sync

ope;

serio

usou

tcom

eswere

defin

edat

thestartof

the

stud

y;allp

atientswere

follo

wed

upto

determ

ine

whe

ther

they

had

expe

rienc

edase

rious

outcom

ewith

in7da

ysof

theirED

visit

684ED

visits

forsync

ope,

with

79of

thes

evisits

resu

lting

inpa

tients

expe

rienc

ingse

rious

outcom

es;of

the50

pred

ictorva

riables

cons

idered

,26were

asso

ciated

with

ase

rious

outcom

eon

univariate

analysis

TheSan

Fran

cisc

oSynco

peRule

deriv

edin

this

coho

rtof

patie

nts

appe

arsto

bese

nsitive

for

iden

tifying

patie

ntsat

riskfor

short-term

serio

usou

tcom

es

Pros

pectivede

rivationstud

yof

San

Fran

cisc

oSynco

peRule

I

Kap

oor

et al3

1983

Pros

pectiveco

hort

stud

yFo

llowed

204pa

tientswith

sync

opeto

determ

ineho

woftenaca

useof

sync

ope

couldbe

establishe

dan

dto

defin

etheprog

nosisof

patie

nts

Aca

rdiova

scular

caus

ewas

establishe

din

53

patie

ntsan

da

nonc

ardiov

ascu

larca

use

in54pa

tients;

theca

use

remaine

dun

know

nin

97

patie

nts

Patie

ntswith

sync

opeca

nbe

sepa

ratedinto

diag

nostic

catego

riesthat

have

prog

nostic

impo

rtan

ce;pa

tientswith

aca

rdiova

scular

caus

eha

vea

strik

inglyhigh

erincide

nceof

sudd

ende

aththan

patie

ntswith

ano

ncardiov

ascu

lar,un

know

nca

use

Study

ofdiag

nosisan

dou

tcom

ein

204sync

ope

patie

nts,

demon

stratin

gincrea

sedmortalityin

thos

ewith

cardiacetiology;

correc

tionmad

eforpa

tient

subg

roup

swith

noch

ange

inresu

lts

II

8 Annals of Emergency Medicine Volume , . : April

Eviden

tiaryTa

ble(con

tinu

ed).

Vos sk ation)

sk ation)

Clinical PolicyStudy

Yea

rDesign

Interven

tion

(s)/

Test(s)/Mod

ality

Outco

meMea

sure/

Criterion

Stand

ard

Results

Limitations/Com

men

tsClas

Martin et al5

1997

Pros

pectivestud

ies

Twopros

pectivestud

ieswere

carriedou

tat

alargeurba

nteac

hing

hosp

italE

D;a

coho

rtof

252pa

tientswith

sync

opepres

entin

gto

the

EDwas

used

tode

velopthe

riskclas

sific

ationsystem

;a

seco

ndco

hortof

374

patie

ntswith

sync

opewas

used

tova

lidatethesystem

Multiv

ariate

pred

ictors

ofarrhythm

iaor

1-y

mortality;

arrhythm

iasor

deathwith

in1y

Historic

alan

dEC

Gfactorsav

ailable

atpres

entatio

nca

nbe

used

tostratifyris

kof

arrhythm

iasor

mortalitywith

in1yin

EDpa

tients

pres

entin

gwith

sync

ope;

multiv

ariate

pred

ictors

ofarrhythm

iaor

1-ymortalitywere:

anab

norm

alED

ECG

resu

lt,historyof

ventric

ular

arrhythm

ia,

historyof

CHF,

orag

e45y;

arrhythm

iasor

deathwith

in1y

occu

rred

in7.3%

(derivation

coho

rt)to

4.4%

(validation

coho

rt)of

patie

ntswith

outan

yris

kfactorsan

din

80.4%

(derivation)

to57.6%

(validation)

ofpa

tientswith

3or

4ris

kfactors

Allp

oten

tialp

redictorswere

includ

eddu

ringde

rivation;

thede

cision

rule

hasbe

enva

lidated

inthis

stud

y;the

deriv

ationan

dva

lidation

data

arese

tinde

pend

entin

2co

horts;

1forde

rivation,

1forva

lidation;

outcom

eswerede

fined

atthestartof

thestud

y;moreEC

Gab

norm

alities

/cardiac

morbidity

inde

rivation

coho

rt;multiv

ariate

regres

sion

analysis

post-

stud

yforsu

bgroup

swith

varia

bles

know

nto

have

differen

tprog

nostic

value;

asse

ssmen

tof

outcom

esno

tblinde

d

I

Crane

13

2002

Retrosp

ectiv

e Study app

lied AC

P ris

kstratifi

catio

n/ad

mit

guidelines

to208pa

tients

evalua

tedwith

sync

ope;

43%

ofco

hortwas

notas

sign

edadiag

nosisaftertheir

asse

ssmen

tin

ED;47(22%)

wereplac

edin

ACPgrou

p1;

63(30%

)in

ACPgrou

p2;

and

100(48%)in

ACPgrou

p3

36%

ofthos

ein

grou

p1,

14%

ofthos

ein

grou

p2,

andno

nein

grou

p3died

with

inay

Itis

poss

ible

toris

k-stratifysync

ope

patie

ntspres

entin

gto

anED

byus

ingAC

Pgu

idelines

for

man

agingsync

ope

Riskstratifi

catio

nsu

cces

sful

base

don

1-ymortality;

noblinding

III(ri

stratifi

c

Kap

oor

et al14

1982

Retrosp

ectiv

e121pa

tientsho

spita

lized

for

sync

opeof

unce

rtainca

use

Thede

finitive

caus

efor

sync

opewas

diag

nose

din

only

13of

121

patie

ntsafterav

erag

eho

spita

lizationof

9da

ys

Find

ings

sugg

estthat

anex

tens

ive

evalua

tionof

sync

opeof

unkn

ownorigin

isco

st-in

effective

andthat

pros

pectivego

al-

directed

approa

ches

shou

ldbe

deve

lope

d

Low

diag

nostic

yieldan

dhigh

cost

ofinpa

tient

evalua

tions

wereno

tedfin

ding

sin

patie

ntswith

outev

iden

tdiag

nosison

initial

evalua

tion

III

Ammira

tiet al17

2000

Sim

plified

2-step

diag

nostic

algo

rithm

was

deve

lope

dan

dpros

pectively

implem

entedin

9co

mmun

ityho

spita

lsin

Lazio

region

ofIta

ly

195co

nsec

utivepa

tients

pres

entin

gwith

sync

opal

spells

toED

sthroug

hout

a2-m

ope

riod

Improv

emen

tin

clinical

decision

mak

ingratedby

percen

tage

ofca

ses

remaining

asu

ndiagn

osed

after

evalua

tion

Thesystem

atic

implem

entatio

nof

theprop

osed

diag

nostic

algo

rithm

resu

ltedin

astrik

ing

redu

ctionof

undiag

nose

dca

ses

Study

exam

ines

theus

eof

adiag

nostic

algo

rithm

tode

term

inetheca

use/

diag

nosisof

sync

ope;

apriorstud

yis

used

asa

con

trolgrou

p;lack

ofris

kstratifi

catio

n,an

dno

sepa

rate

deriv

ation

(con

sens

usthroughliterature)

andva

lidationse

tof

data;it

isun

clea

rho

wdiag

nose

swerereac

hedan

dho

wdiag

nose

swereva

lidated

III(ri

stratifi

c

lume , . : April Annals of Emergency Medicine 439

Eviden

tiaryTa

ble(con

tinu

ed).

Cl

44s

inical PolicyStudy

Yea

rDesign

Interven

tion

(s)/

Test(s)/Mod

ality

Outco

meMea

sure/

Criterion

Stand

ard

Results

Limitations/Com

men

tsClas

Saras

inet al18

2001

Pros

pective

Con

secu

tivepa

tientswho

pres

entedto

theED

with

sync

opeas

ach

ief

complaint

wereen

rolle

d

Adiag

nosisof

etiology

ofsync

opeor

sync

ope

subtype

Thediag

nostic

yieldof

astan

dardized

evalua

tionof

sync

opewas

76%,includ

ingthe

useof

spec

ialized

cardiova

scular

testsin

selected

patie

nts

Lack

ofcrite

rionstan

dard

tova

lidatediag

nosis

II

Colivicch

iet al19

2003

Pros

pective

multic

enter

270co

nsec

utivepa

tients

pres

entin

gwith

sync

opeto

theED

sof

6co

mmun

ityho

spita

lswas

used

asa

deriv

ationco

hortforthe

deve

lopm

entof

theris

kclas

sific

ationsystem

;da

tafrom

theba

selin

eclinical

history,

physical

exam

ination,

andEC

Gwereus

edto

iden

tifyinde

pend

ent

pred

ictors

oftotalm

ortality

with

inthefirst

12moafter

theinitial

evalua

tion;

risk

clas

sific

ationsc

oringwas

pros

pectivelyco

nfirm

edin

ava

lidationco

hortof

328

cons

ecutivepa

tients

Multiv

ariate

pred

ictors

ofde

athwith

in1y

Clin

ical

andEC

Gfactorsav

ailable

atpres

entatio

nca

nbe

used

tostratifyris

kof

mortalitywith

in1y

inpa

tientspres

entin

gwith

sync

ope

Multiv

ariate

analysis

show

edthefollo

wingpred

ictors

ofmortality:

(1)ag

e65y;

(2)

cardiova

scular

dise

asein

clinical

history;

(3)sync

ope

with

outprod

romes

;an

d(4)

abno

rmal

elec

troc

ardiog

ram;

mortalityincrea

sed

sign

ifica

ntly

asthesc

ore

increa

sedin

thede

rivation

coho

rt(0%

forasc

oreof

0,

0.8%

for1po

int;19.6%

for

2po

ints;34.7%

for3

points;57.1%

for4po

ints)

I

Quinn et al20

2006

Pros

pectiveco

hort

stud

yto

valid

ate

prev

ious

deriv

ationse

t

Physicians

pros

pectively

completed

astructured

data

form

whe

nev

alua

ting

patie

ntswith

sync

ope;

serio

usou

tcom

eswere

defin

edat

thestartof

the

stud

y;allp

atientswere

follo

wed

upto

determ

ine

whe

ther

they

had

expe

rienc

edase

rious

outcom

ewith

in7da

ysof

theirED

visit

791visits

forsync

ope;

53

(6.7%)resu

ltedin

bad

outcom

es

Therule

was

98%

sens

itive

(95%

CI

89%-100%)an

d56%

spec

ific

(95%

CI52%-60%)to

pred

ict

adve

rseou

tcom

es;LR

()2.2;

LR(-)

0.04

Singleinstitu

tion

I


Eviden

tiaryTa

ble(con

tinu

ed).

Vos sk ation)

k ation)


Yea

rDesign

Interven

tion

(s)/

Test(s)/Mod

ality

Outco

meMea

sure/

Criterion

Stand

ard

Results

Limitations/Com

men

tsClas

Saras

inet al21

2003

Pros

pective

valid

ationan

dretros

pective

deriv

ation

175pa

tientswith

unex

plaine

dsyncop

e(Gen

eva,

Switzerland

)wereus

edto

deve

lopan

dcros

s-va

lidatetheris

ksc

ore;

ase

cond

coho

rtof

269

simila

rpa

tients(Pittsb

urgh

)was

used

tova

lidatethe

system

;da

tafrom

patie

nts

historyan

d12-le

adem

erge

ncyEC

Gwereus

edto

iden

tifypred

ictors

ofarrhythm

ias;

risk-sc

ore

performan

cewas

mea

sured

bycompa

ringtheprop

ortio

nsof

patie

ntswith

arrhythm

iasat

vario

uslevelsof

thescorean

dRO

Ccurves

Theprev

alen

ceof

arrhythm

icsync

opewas

17%

inthede

rivation

coho

rtan

d18%

inthe

valid

ationco

hort;

pred

ictors

ofarrhythm

ias

wereab

norm

alEC

Gresu

lt,ahistoryof

CHF,

andag

eolde

rthan

65y

Inpa

tientswith

unex

plaine

dsync

ope,

aris

ksc

oreba

sedon

clinical

andEC

Gfactorsav

ailable

intheED

iden

tifies

patie

ntsat

riskforarrhythm

ias

Derivationgrou

p10ylater

than

valid

ationgrou

p;ve

ryse

lected

patie

ntgrou

p

III(ri

stratifi

c

Soteriade

set al22

2002

Retrosp

ectiv

eFram

ingh

amda

taba

se1971-

1998

Study

evalua

ting

popu

latio

n-ba

sed

incide

ncean

dou

tcom

eof

sync

ope

Of7,812pa

tientspa

rticipatingin

thestud

y,822ha

dsync

ope;

incide

nce6.2/1

,000;36.6%

sync

opeun

know

nca

use

Thos

ewith

sync

opeha

dhigh

ermortalityrates,

and

even

moreso

whe

nitwas

cardioge

nicsync

ope;

selected

popu

latio

n;inclus

ioncrite

riaof

basic

stud

ypo

pulatio

nun

clea

rin

this

artic

le

II(ris

stratifi

c

Graha

man

dKen

ny25

2001

Pros

pective

62pa

tientswith2ep

isod

esof

sync

opein

thepa

sty

referred

forad

ditio

nal

testing;

thos

ewho

hada

positiv

etilttabletest

andno

othe

riden

tified

caus

efor

sync

opewereas

sign

eda

diag

nosisof

vaso

vaga

lsync

ope

Tilt-tabletestingwas

performed

usinga

stan

dard

protoc

ol

Patie

ntsiden

tified

asvaso

depres

sor

sync

opeby

virtue

ofpo

sitivetilt

test

weregivenaqu

estio

nnaire;up

toon

ethird

lacked

trad

ition

alsymptom

sas

sociated

with

vaso

depres

sorsync

ope;

atypical

pres

entatio

nsof

vaso

vagalsyncope

occu

rin

man

ypa

tientsreferred

toatertiaryreferra

lcen

ter;know

ledge

oftheclinical

charac

teris

ticsof

unexplaine

dsync

opeforwhich

vaso

vaga

lsynco

pewas

the

determ

ined

diag

nosissh

ould

assist

inap

prop

riate

man

agem

ent

ofsu

chpa

tients

Selec

tion/

referral

bias

;no

true

crite

rionstan

dard

for

diag

nosis

III


Eviden

tiaryTa

ble(con

tinu

ed).

Cl

44s

inical PolicyStudy

Yea

rDesign

Interven

tion

(s)/

Test(s)/Mod

ality

Outco

meMea

sure/

Criterion

Stand

ard

Results

Limitations/Com

men

tsClas

Oh et al31

1999

Pros

pective co

hort

Interview and

rev

iew of ch

art to

obtain

inform

ationon

19

symptom

san

dco

morbiditie

s

Arrhythm

ias,

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orrecu

rren

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ope

497pa

tientsen

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in22

2ca

use

ofsync

opees

tablishe

dby

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andph

ysical

exam

ination;

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othe

r27

5,theab

senc

eof

naus

eaan

dvomiting

orpres

ence

ofeletroca

rdiograp

hicab

norm

alities

werepred

ictiveof

arrhythm

icsync

ope;

unde

rlyingca

rdiac

dise

asewas

theon

lypred

ictorof

1-ymortality;

symptom

swereno

tus

eful

inris

kstratifi

catio

n

Selec

tionbias

bystud

ypo

pulatio

nfrom

tertiary

sync

opece

nter

II

Kap

ooran

dHan

usa3

21996

Pros

pectiveca

seco

ntrol

470sync

opepa

tientsan

d470

match

edpa

tientswith

out

sync

ope

Thech

arac

teris

ticsof

470

patie

ntswith

sync

ope

weresimila

r,ex

cept

that

thepa

tientswith

out

sync

opeha

dmore

cardiacdise

ases

than

thos

ewith

sync

ope

Synco

peits

elfis

notaris

kfactor

forov

eralla

ndca

rdiacmortality

orca

rdiova

scular

even

ts;

unde

rlyinghe

artdise

ases

were

riskfactorsformortality

rega

rdless

ofwhe

ther

thepa

tient

hadsync

opeor

not

Forsu

bgroup

swith

impo

rtan

tprog

nostic

differen

ces,

adjustmen

tsweremad

efor

thes

efactors;

asse

ssmen

tof

outcom

eswas

blinde

d;follo

w-upwas

sufficien

tlylong

andco

mplete;

survival

curves

arepres

ented

II

Middlek

auff

et al33

1993

Popu

latio

nwith

adva

nced

heart

failu

repros

pectively

iden

tified

;retros

pective

review

ofhistorical

inform

ationan

ddiag

nostic

tests

Therelatio

nof

sync

opeto

sudd

ende

athwas

evalua

ted

in491co

nsec

utivepa

tients

with

adva

nced

heartfailu

re,

nohistoryof

cardiacarrest,

andamea

nleftve

ntric

ular

ejectio

nfra

ctionof

0.200.07

;sync

opepa

tients(60)an

dno

nsynco

pepa

tients(431)

with

CHFclas

sIII-IV

were

compa

red

60pa

tients(12%)ha

da

historyof

sync

ope;

sync

opeha

daca

rdiac

origin

in29(48%)an

dwas

dueto

othe

rca

uses

in31(52%);su

dden

deathwas

prim

ary

endp

oint

Patie

ntswith

adva

nced

heartfailu

reareat

espe

cially

high

riskfor

sudd

ende

athrega

rdless

ofthe

etiology

ofsync

ope

Con

trol

grou

pmuc

hlarger

than

referenc

egrou

p;all

patie

ntsin

samestag

eof

dise

ase(NYH

A3-4,no

historyof

cardiacarrest

and

LVEF

0.200.07);se

lected

grou

p

II

Saras

inet al34

2002

Pros

pective

Ortho

static

bloo

dpres

sure

chan

gesweremea

suredin

astan

dardized

fash

ionforup

to10min,or

until

symptom

soc

curred

,in

cons

ecutivepa

tientswith

sync

opeas

ach

ief

complaint

Ortho

static

bloo

dpres

sure

chan

ges

Acco

rdingto

diag

nostic

crite

ria,

orthos

tatic

hypo

tens

ionwas

cons

idered

tobe

theca

useof

sync

opein

156pa

tients(24%

);58

patie

nts(37%

)ha

ddrug

-indu

ced

hypo

tens

ion;

33(21%

)ha

dhypo

volemia;19

(12%

)ha

dpo

st-

pran

dial

hypo

tens

ion;

and46

(29%

)ha

didiopa

thic

hypo

tens

ion

788pa

tientswith

sync

ope

seen

,bu

tbe

caus

eof

refusa

lor

inco

mpleteda

ta,on

ly65

0includ

edin

thestud

y;57

9(89%

)ha

dstan

dardized

mea

suremen

tsof

systolic

bloo

dpres

sure

with

othe

rexclus

ions

includ

inginab

ility

tostan

dup

III


Eviden

tiaryTa

ble(con

tinu

ed).

Vos k ation)

k ation)

sion

)

YHA,


Yea

rDesign

Interven

tion

(s)/

Test(s)/Mod

ality

Outco

meMea

sure/

Criterion

Stand

ard

Results

Limitations/Com

men

tsClas

Eaglean

dBlack

36

1983

Retrosp

ectiv

e100pa

tientsad

mitted

tothe

hosp

italfor

evalua

tionof

sync

ope

In39pa

tients,

noetiology

for

sync

opewas

foun

d,an

dan

othe

r18werethou

ghtto

have

hada

vaso

vaga

lepiso

de;12pa

tients

hadarrhythm

iasas

theca

usefor

sync

ope

Study

includ

esho

spita

ltes

ting

butno

follo

w-upbe

yond

initial

evalua

tion;

nostan

dard

evalua

tion;

difficu

ltto

useforris

kstratifi

catio

nbe

caus

eof

selectionbias

III

Saras

inet al40

2002

Pros

pective

650co

nsec

utivepa

tientswith

sync

opean

dclinical

susp

icionof

anob

structive

valvular,or

with

sync

openo

tex

plaine

dby

history,

physical

exam

ination,

orEC

Gun

derw

entec

hoca

rdiograp

hy

Theca

uses

ofsync

ope

wereas

sign

edus

ing

publishe

ddiag

nostic

crite

ria

Echo

cardiograp

hywas

useful

only

inpa

tientswith

abno

rmal

ECG

resu

lts,historyof

cardiac

dise

ase,

orsymptom

san

dsign

sof

aortic

sten

osis

Smalls

amplesize

ofpa

tients

with

unex

plaine

dsync

ope

II(ris

stratifi

c

Morag et al41

2004

Pros

pective,

short-

term

outcom

esstud

y

45pa

tientsmet

inclus

ion

crite

ria:no

ndiagn

ostic

EDev

alua

tion;

67%

were

hosp

italized

onmon

itored

bed

Interven

tionforarrhythm

iadu

ringho

spita

lization;

interviewsat

1mo

This

pilotstud

ysu

gges

tsthat

ane

gativ

e-structured

EDev

alua

tion

may

iden

tifypa

tients50yof

agewho

may

besa

fely

disc

harged

from

theED

;no

neof

thepa

tientsex

perie

nced

alife-

threaten

ingev

entor

requ

ired

sign

ifica

nttherap

eutic

interven

tions

durin

gho

spita

lization;

nopa

tient

hada

new

diag

nosisreleva

ntto

sync

ope

Study

raises

ques

tion:

isho

spita

lizationne

cess

ary;

howev

er,sa

mplesize

too

smalltoas

sess

;no

control

grou

pus

ed;ou

tcom

esde

fined

atthestartof

the

stud

y;pa

tientsin

differen

tstag

esin

theirdise

ase

III

She

n et al42

2004

Pros

pective

Patie

ntswererand

omly

alloca

tedto

2trea

tmen

tarms:

sync

opeun

itev

alua

tionan

dstan

dard

care;103co

nsec

utive

patie

ntsen

teredthestud

y

Pres

umptivediag

nosis,

hosp

italizationrate,an

dpa

tient

hosp

itald

ays

103co

nsec

utivepa

tientswith

sync

ope;

51pa

tientswere

rand

omized

tothesync

opeun

it;forsync

opeun

itpa

tients,

the

pres

umptivediag

nosiswas

establishe

din

34(67%)vs

5(10%)of

stan

dard

care

patie

nts;

totalp

atient

hosp

itald

ayswere

redu

cedfrom

140to

64

Ran

domized

trialfor

EDob

servationun

itfor

interm

ediate

risksync

ope;

smalln

umbe

rsan

dfairly

soph

istic

ated

evalua

tions

intheED

limitge

neralizab

ility;

selectionbias

:se

lected

interm

ediate

riskgrou

p

II(ris

stratifi

c III(adm

is

ACP,

American

College

ofPh

ysicians

;CHF,

cong

estiv

ehe

artfailu

re;EC

G,elec

troc

ardiog

ram;ED

,em

erge

ncyde

partmen

t;LVEF

,leftve

ntric

ular

ejec

tionfrac

tion;

LR,lik

elihoo

dratio

;min,minute;

mo,

mon

th;N

New

York

Hea

rtAs

sociation;

ROC,rece

iver

operatingch

arac

teris

tic;y,

year.


Appendix A. Literature classification schema.*

Design/Class Therapy Diagnosis Prognosis

1 Randomized, controlled trial or meta-analysesof randomized trials

Prospective cohort using a criterion standard Population prospective cohort

2 Nonrandomized trial Retrospective observational Retrospective cohortCase control

3 Case seriesCase reportOther (eg, consensus, review)

Case seriesCase reportOther (eg, consensus, review)

Case seriesCase reportOther (eg, consensus, review)

*Some designs (eg, surveys) will not fit this schema and should be assessed individually.Objective is to measure therapeutic efficacy comparing 2 interventions.Objective is to determine the sensitivity and specificity of diagnostic tests.Objective is to predict outcome including mortality and morbidity.

Appendix B. Approach to downgrading strength of evidence.

Downgrading

Design/Class

1 2 3

None I II III1 level II III X2 levels III X XFatally flawed X X X

Clinical Policy


Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with SyncopeINTRODUCTIONMETHODOLOGYLevel A recommendationsLevel B recommendationsLevel C recommendationsAppendix A. Literature classification schemaAppendix B. Approach to downgrading strength of evidenceScope of ApplicationInclusion CriteriaExclusion Criteria

CRITICAL QUESTIONS1. What history and physical examination data help to risk-stratify patients with syncope?Level A recommendationsLevel B recommendationsLevel C recommendations

2. What diagnostic testing data help to risk-stratify patients with syncope?Level A recommendationsLevel B recommendationsLevel C recommendations

3. Who should be admitted after an episode of syncope of unclear cause?Level A recommendationsLevel B recommendationsFigure. Factors that lead to stratification as high-risk for adverse outcome

Level C recommendations

Future DirectionsREFERENCESEvidentiary Table

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