Abstract
IntroductionWe performed a systematic review and meta-analysis to identify predictors of serious clinical outcomes after an acute-care evaluation for syncope.MethodsWe identified studies that assessed for predictors of short-term (≤30 days) serious clinical events after an emergency department (ED) visit for syncope. We performed a MEDLINE search (January 1, 1990 – July 1, 2017) and reviewed reference lists of retrieved articles. The primary outcome was the occurrence of a serious clinical event (composite of mortality, arrhythmia, ischemic or structural heart disease, major bleed, or neurovascular event) within 30 days. We estimated the sensitivity, specificity, and likelihood ratio of findings for the primary outcome. We created summary estimates of association on a variable-by-variable basis using a Bayesian random-effects model.ResultsWe reviewed 2,773 unique articles; 17 met inclusion criteria. The clinical findings most predictive of a short-term, serious event were the following: 1) An elevated blood urea nitrogen level (positive likelihood ratio [LR+]: 2.86, 95% confidence interval [CI] [1.15, 5.42]); 2); history of congestive heart failure (LR+: 2.65, 95%CI [1.69, 3.91]); 3) initial low blood pressure in the ED (LR+: 2.62, 95%CI [1.12, 4.9]); 4) history of arrhythmia (LR+: 2.32, 95%CI [1.31, 3.62]); and 5) an abnormal troponin value (LR+: 2.49, 95%CI [1.36, 4.1]). Younger age was associated with lower risk (LR−: 0.44, 95%CI [0.25, 0.68]). An abnormal electrocardiogram was mildly predictive of increased risk (LR+ 1.79, 95%CI [1.14, 2.63]).ConclusionWe identified specific risk factors that may aid clinical judgment and that should be considered in the development of future risk-prediction tools for serious clinical events after an ED visit for syncope.
Highlights
We performed a systematic review and meta-analysis to identify predictors of serious clinical outcomes after an acute-care evaluation for syncope
We identified studies that assessed for predictors of short-term (≤30 days) serious clinical events after an emergency department (ED) visit for syncope
We identified specific risk factors that may aid clinical judgment and that should be considered in the development of future risk-prediction tools for serious clinical events after an ED visit for syncope. [West J Emerg Med. 2018;19(3)517–523.]
Summary
We performed a systematic review and meta-analysis to identify predictors of serious clinical outcomes after an acute-care evaluation for syncope. There are over 1.3 million annual events of syncope (transient loss of consciousness with rapid and spontaneous recovery1) in the United States that lead to an emergency department (ED) visit, resulting in 440,000 admissions[2] and $2.4 billion in yearly hospital costs.[3] Syncope may be a harbinger of sudden death, dangerous arrhythmias, or other serious medical conditions (e.g., pulmonary embolism). To mitigate the risk of sudden death or other dangerous clinical events, up to 85%5 of older adults who present with syncope of unclear cause are hospitalized for a diagnostic evaluation.[6,7] admission is associated with low diagnostic and therapeutic yield,8.9 and there is no evidence that current practice patterns improve quality of life or long-term survival.[10]
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