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. 2020 May 1;180(5):737-744.
doi: 10.1001/jamainternmed.2020.0288.

Multicenter Emergency Department Validation of the Canadian Syncope Risk Score

Venkatesh Thiruganasambandamoorthy  1   2   3 , Marco L A Sivilotti  4   5 , Natalie Le Sage  6   7 , Justin W Yan  8 , Paul Huang  9 , Mona Hegdekar  10 , Eric Mercier  6   7 , Muhammad Mukarram  2 , Marie-Joe Nemnom  2 , Andrew D McRae  11   12 , Brian H Rowe  13   14 , Ian G Stiell  1   2   3 , George A Wells  3 , Andrew D Krahn  15 , Monica Taljaard  2   3
Affiliations

Multicenter Emergency Department Validation of the Canadian Syncope Risk Score

Venkatesh Thiruganasambandamoorthy et al. JAMA Intern Med. .

Abstract

Importance: The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use.

Objective: To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation.

Design, setting, and participants: This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018.

Main outcomes and measures: Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated.

Results: A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively.

Conclusions and relevance: The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Le Sage reports receiving grants from the Cardiac Arrhythmia Network of Canada. Dr Sivilotti reports receiving grants from the Canadian Institutes of Health Research, the Heart and Stroke Foundation of Canada, and the Cardiac Arrhythmia Network of Canada. Dr Thiruganasambandamoorthy reports receiving grants from the Heart and Stroke Foundation of Canada and the Cardiac Arrhythmia Network of Canada, as well as honorarium and travel expenses for attending a focus group on syncope by Medtronic. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patient Flowchart
Abbreviations: ED, emergency department; LOC, loss of consciousness; LWBS, left without being seen (left before physician assessment).
Figure 2.
Figure 2.. Calibration Plot of Expected vs Observed Risk in the Validation Cohort
Vertical lines represent the 95% CI. The marks on the lower horizontal line represent the frequency distribution of patients across expected risk categories. ROC indicates receiver operating characteristic curve.
See this image and copyright information in PMC

Comment in

References

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