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Determining the appropriate disposition of emergency department (ED) syncope patients is challenging. Previously developed decision tools have poor diagnostic test characteristics and methodological flaws in their derivation that preclude their use. We sought to develop a scale to risk-stratify adult ED syncope patients at risk for serious adverse events (SAEs) within 30 days.
We conducted a medical record review to include syncope patients age ≥ 16 years and excluded patients with ongoing altered mental status, alcohol or illicit drug use, seizure, head injury leading to loss of consciousness, or severe trauma requiring admission. We collected 105 predictor variables (demographics, event characteristics, comorbidities, medications, vital signs, clinical examination findings, emergency medical services and ED electrocardiogram/ monitor characteristics, investigations, and disposition variables) and information on the occurrence of predefined SAEs. Univariate and multiple logistic regression analyses were performed.
Among 505 enrolled patient visits, 49 (9.7%) suffered an SAE. Predictors of SAE and their resulting point scores were as follows: age ≥ 75 years (1), shortness of breath (2), lowest ED systolic blood pressure < 80 mm Hg (2), Ottawa Electrocardiographic Criteria present (2), and blood urea nitrogen > 15 mmol/L (3). The final score calculated by addition of the individual scores for each variable (range 0–10) was found to accurately stratify patients into low risk (score < 1, 0% SAE risk), moderate risk (score 1, 3.7% SAE risk), or high risk (score > 1, ≥ 10% SAE risk).
We derived a risk scale that accurately predicts SAEs within 30 days in ED syncope patients. If validated, this will be a potentially useful clinical decision tool for emergency physicians, may allow judicious use of health care resources, and may improve patient care and safety.
Previous studies have indicated that the sub-optimal performance of the San Francisco Syncope Rule (SFSR) is likely due to the misclassification of the “abnormal electrocardiogram (ECG)” variable. We sought to identify specific emergency department (ED) ECG and cardiac monitor abnormalities that better predict cardiac outcomes within 30 days in adult ED syncope patients.
This health records review included patients 16 years or older with syncope and excluded patients with ongoing altered mental status, alcohol or illicit drug use, seizure, head injury leading to loss of consciousness, or severe trauma requiring admission. We collected patient characteristics, 22 ECG variables, cardiac monitoring abnormalities, SFSR “abnormal ECG” criteria, and outcome (death, myocardial infarction, arrhythmias, or cardiac procedures) data. Recursive partitioning was used to develop the “Ottawa Electrocardiographic Criteria.”
Among 505 included patient visits, 27 (5.3%) had serious cardiac outcomes. We found that patients were at risk for cardiac outcomes within 30 days if any of the following were present: second-degree Mobitz type 2 or third-degree atrioventricular (AV) block, bundle branch block with first-degree AV block, right bundle branch with left anterior or posterior fascicular block, new ischemic changes, nonsinus rhythm, left axis deviation, or ED cardiac monitor abnormalities. The sensitivity and specificity of the Ottawa Electrocardiographic Criteria were 96% (95% CI 80–100) and 76% (95% CI 75–76), respectively.
We successfully identified specific ED ECG and cardiac monitor abnormalities, which we termed the Ottawa Electrocardiographic Criteria, that predict serious cardiac outcomes in adult ED syncope patients. Further studies are required to identify which adult ED syncope patients require cardiac monitoring in the ED and the optimal duration of monitoring and to confirm the accuracy of these criteria.
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