Why Does CV Disease Matter?
Bottom Line: Cardiac etiologies of syncope (red line above) have the highest associated mortality!
Do Risk Stratification Tools Work?
There is no “gold standard” evaluation for syncope, but there are several different scores and more coming out every month. Here is a list of several:
These rules are difficult to evaluate in part because of different weights on different variables contributing to the scoring system. A major problem with most of these scoring systems is that older patients are underrepresented. This is an issue because as our patient population gets older so does the incidence of syncope and the incidence of cardiac etiologies.
Bottom Line: Educated clinician judgment based on EBM guidelines ( European Society for Cardiology and ACEP ) seems to be the best strategy for management. Syncope prediction rules can certainly aid this process, but they do not yet fit for use alone for risk stratification in any population.
What is the ACEP Level-B Recommendation for Admission ?
Does Everyone with Syncope Need a Head CT?
ACEP's Level C recommendation states Cranial CT scanning need NOT be routinely performed unless guided by specific findings in the history or physical exam. So what are those findings?
Do Syncope Management Units (SMUs) Increase Diagnostic Yield & Decrease Hospital Admissions?
Below are the findings from the Syncope Evaluation in the Emergency Department Study (SEEDS) study
Bottom Line: This is an interesting concept and shows decreased hospital admission. This particular study, however, was poorly powered, unblinded, and had no cost-benefit analysis. A multicenter, multidisciplinary study would need to be performed to externally, validate and standardize the risk stratification scheme and concept of a SMU before implementation.
It is our job as emergency physicians to NOT identify a precise cause of syncope. Instead, we should aim to risk-stratify our patients: Who needs to be hospitalized (high risk) versus who can be safely discharge home (low risk) with outpatient follow up? The keys are: