Background: Syncope is a common presenting complaint and it can be difficult to decide which patients need admission, particularly if no cause is found. Clinical decision rules (San Francisco syncope score, OESIL score, EGSYS score, ROSE score, Canadian Syncope Risk Score) are not used widely due to poor sensitivity and lack of external validation. San Francisco is probably the best-known of these, but this external validation study in 2009 only found a sensitivity of 74%, much lower than in the original research. Thankfully, the ever-busy European Society of Cardiology recently updated their 2009 guidance for managing syncope in the ED. It’s a chunky document, but here we’ll just focus on the recommendations for which patients need admission. (European Heart Journal, June 2018)

 

Low-risk features:– Typical prodrome (light-headedness, warmth, sweating, nausea)– Provocation (unpleasant sensation, hot environment, postprandial, or triggered by cough, defaecation or micturition)– Position (prolonged standing or on standing)– Long history of recurrent syncope with low-risk features– Normal examination– Normal ECG

These patients are very likely to have reflex, situational or orthostatic syncope and can be discharged directly from the ED

 

High-risk features:– Chest pain, breathlessness, abdominal pain or headache– Syncope preceded by palpitations– Syncope during exertion or when supine– Structural heart disease or severe heart failure– Unexplained hypotension or GI bleed– Undiagnosed systolic murmur– Abnormal ECG (acute ischaemia, AV blocks or sinus pauses, tachyarrhythmias, long QT, HOCM, Brugada, WPW )

These patients should be admitted for further investigation

 

Note: patients with neither high nor low risk features should be observed for a period in a ‘Syncope Unit’ or receive close follow up in an outpatient Syncope Clinic