Risk Stratification of Syncope in the Emergency Department, Clinical Decision Rules or Clinical Judgement?

Abstract

Aim: Clinical decision tools (CDTs) have been developed to assess patients with syncope. None have shown clear superiority to identify patients at high risk of adverse outcome. The aim of this study was to validate a modified Risk Stratification of Syncope in the Emergency Department (ROSE) CDT (without a brain natriuretic peptide (BNP) assay and also evaluate a proposed ROSE-65 rule (substituting age 65 for serum BNP), comparing these with the performance of existing CDTs, the San Francisco Syncope Rule (SFSR) and the Osservatorio Epidemiologico per la Sincopenel Lazio (OESIL). Methods: This was a single center, retrospective observational study of adults presenting to the ED with syncope. OESIL, SFSR, ROSE Rule minus BNP and ROSE-65 were applied to assess outcomes at 1-week, 1-month and 1-year follow up. Results: 120 patients had data for full analysis. ROSE (minus BNP) showed sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of 80.0%, 81.7%, 16.0% and 98.9%, and 4.38 and 0.25, respectively for adverse outcome at 1-week. Use of this CDT would have been prevented 26 admissions and missed 1 adverse outcome compared to clinical care at short term. The ROSE-65 showed sensitivity 80.0% and specificity 64.3%, and would have prevented 6 admissions while missing 1 adverse outcome. Both performed better than OESIL and SFSR. Conclusion: ROSE (without BNP) and ROSE-65 performed better than OESIL and SFSR in terms of sensitivity and specificity. ROSE saved 26 admissions, missing only 1 adverse outcome at short term follow up. ROSE Rule (without BNP) showed similar performance compared to the initial derivation study. The ROSE Rule, minus BNP, seems a promising tool resulting in more prevented admissions and fewer missed adverse outcomes compared to clinical care and all other CDTs.