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Evaluation of syncope patients in the emergency department (ED) is challenging due to the broad spectrum of differential diagnosis ranging from benign to life-threatening conditions. We examined the accuracy of two syncope decision tools (San Francisco Syncope Rule, Bos-ton Criteria) in a German ED.
Study design, methods: This is a single-center, retrospective study of patients presenting with syncope or near-syncope to the ED of the Nuremberg Hospital. The primary endpoint is defined as adverse outcome during hospitalization or 7-day follow-up after discharge.
Results: 440 of 28477 patients (1.5%) presenting with syncope to our ED and complete fol-low-up were included in the analysis. 79.3% of patients were hospitalized and 84 patients (19.01%) experienced the primary endpoint. Cardiac and arrhythmic conditions (39.3%), significant hemorrhage or anemia (16.7%) and severe infections (20.2 %) were the main causes of serious adverse events. Using the San Francisco Syncope Rule or Boston criteria for prediction of the primary endpoint, 57 of 84 patients (sensitivity: 67.9%; specificity: 71.0%; negative predictive value: 90.0%) or 74 of 84 patients would have been identified (sensitivity: 88.1%; specificity: 46.6%; negative predictive value: 94.3%). The sensitivity of each decision strategy increases with age and increasing rates of comorbid conditions, while the specificity of decision rules is lost.
Conclusion: Patients with syncope presenting to a German ED display a high proportion of life-threatening conditions. Clinical decision tools for syncope evaluation, which have been promising in US-american EDs, show an unacceptable low sensitivity to identify patients at increased risk for short-term adverse events.