June 13, 2019

Background Information: Syncope is defined as a sudden transient loss of consciousness (LOC) followed by complete resolution. It represents 1-3% of all emergency department (ED) visits. 1 1% of all hospitalizations are due to syncope as it may have resulted from a serious underlying condition, such as arrhythmia, acute cardiac ischemia, pulmonary embolism or internal hemorrhage. 2,3 Prior studies have demonstrated that up to a half of these serious conditions, particularly arrhythmias, are missed during ED evaluation and become evident after disposition. 1 Several risk stratification tools, such as the Canadian Syncope Risk Score (CSRS; Figure 1) and the San Francisco Syncope Rule (SFSR; Figure 2) have been developed to help identify serious outcomes. 4,5 The authors of this study sought to describe the time to occurrence of serious arrhythmias relative to when the patient arrived in the ED and based on their CSRS risk category. Furthermore, their goal was to use the results of this study to provide guidance for decision making regarding duration and location of cardiac monitoring.

May 30, 2019

Background: Syncope, defined as a transient loss of consciousness with spontaneous and complete recovery to pre-event status, is a common emergency department (ED) presentation. Recently, we have discussed the lack of clinical utility in distinguishing syncope from near-syncope in terms of outcomes. In that discussion, we concluded: “In older adults (> 60 years of age), near-syncope appears to portend an equal risk of death or serious clinical event at 30 days when compared to syncope. These two entities should be considered as one when decisions are made in terms of evaluation in the ED.” While we argue for evaluation and disposition to be the same, we don’t address what the best disposition or plan is. While it is common to admit older patients with syncope/near-syncope from the ED, admission doesn’t inherently yield better outcomes.

February 11, 2019

Background: Syncope, defined as a transient loss of consciousness with a complete recovery, is a common ED presentation. There are numerous causes of syncope ranging from the relatively benign (eg vasovagal syncope) to the potentially life-threatening (eg dysrhythmia, ectopic pregnancy, aortic dissection). Among the life-threatening diagnoses is pulmonary embolism (PE). PE is a common cause of sudden, unexpected, non-traumatic death and, syncope in the setting of PE portends poor 30-day outcomes (Roncon 2018). What is not well known is how often ED presentations of syncope are the result of PE. A study in 2016 demonstrated a 17.3% rate of PE in first time syncope presenting to the ED but, had numerous significant biases and limitations (Prandoni 2016). Ultimately, this study is unlikely to reflect the reality of ED syncope cases and lacks external validity. Incorporating the PESIT trial data into clinical assessment would lead to a profound increase in PE evaluation without adding significant benefit. Additional clinical data demonstrating the true prevalence of PE in syncope patients is needed to confirm these suspicions.

January 7, 2019

Background: Syncope, defined as a transient loss of consciousness with spontaneous and complete recovery to pre-event status, is a common emergency department (ED) presentation. Near-syncope is frequently seen as well. Unlike syncope, near-syncope has a more nebulous definition often thought of as the feeling of oncoming syncope without a complete loss of consciousness. Regardless of definition, many providers consider syncope and near-syncope as two ends of a spectrum of disease with near-syncope being not as dangerous and syncope being more dangerous. The literature on this, however, is inconsistent with a 2009 study stating that near-syncope was a “low-risk" factor (Sun 2009) and a 2015 study showing the opposite (Thiruganasambandamoorthy 2015). Additional high-quality data in this area is needed to further elucidate the risk of near-syncope presentations in the ED.

September 11, 2017

Background: Syncope, the sudden, brief loss of consciousness followed by spontaneous, complete recovery is a common presentation to the Emergency Department (ED). It represents a significant portion of overall admissions to the hospital because while many cases are benign (i.e. vasovagal syncope), some may result from a life-threatening cause (ventricular tachydysrhythmia, myocardial ischemia, gastrointestinal bleeding etc). Admission or 24 hour observation is often sought for continuous dysrhythmia monitoring but they are infrequently found. A decision instrument directed at stratifying patients to high or low risk for a dysrhythmia causing syncope (and thus subsequent risk for a recurrent dysrhythmia) would be useful in managing patients with syncope.