Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department

Abstract

The optimal emergency department (ED) evaluation of syncope is uncertain. Research reports from multiple countries suggest extensive practice variation, high costs, and questionable benefit associated with current approaches.1–5 Moreover, only a few of the recommendations from international syncope guidelines deal with ED management.6–8 For example, the European Society of Cardiology guidelines, which are the most inclusive syncope guidelines, do not address the ED management. This could be due to limited evidence on how to stratify the risk and decide on disposition of these patients in the ED.1,9 We organized a multi-specialty workshop of North American and European syncope experts on 26–27 September 2013 in Gargnano, Italy, with the aim of obtaining a modified Delphi consensus on the best way to manage ED syncope patients. As already described,10 we followed a four-step conceptual model for the ED decision-making in syncope: (i) Is it syncope? (ii) Is there a serious underlying condition identified in the ED? (iii) If the cause is uncertain, what is the risk of a serious outcome? (iv) For a given risk profile, how can these patients be best managed in the ED and what evaluation and restrictions are required? ( Figure 1 ) . Figure 1 Conceptual model: ED management of syncope. Expert recruitment and consensus development have been described previously.10 Details can be found in Supplementary material online, Appendix S1 . The full list of questions and answers to the first and second survey rounds as well as the degree of agreement on each item is reported in Supplementary material online, Appendix S2 . According to the ESC guidelines, syncope is defined as a …