External validation of the San Francisco syncope rule in the Canadian setting

Venkatesh Thiruganasambandamoorthy, Erik P. Hess, Abdullah Alreesi, Jeffrey J. Perry, George A. Wells, Ian G. Stiell

Research output: Contribution to journalReview article

58 Citations (Scopus)

Abstract

Study objective: Syncope is a common disposition challenge for emergency physicians. Among the riskstratification instruments available, only the San Francisco Syncope Rule is rigorously developed. We evaluate its performance in Canadian emergency department (ED) syncope patients. Methods: This retrospective review included patients aged 16 years or older who fulfilled the definition of syncope (transient loss of consciousness with complete recovery) and presented to a tertiary care ED during an 18-month period. We excluded patients with ongoing altered mental status, alcohol/illicit drug use, seizure, and head and severe trauma. Patient characteristics, 5 predictors for the rule (history of congestive heart failure, hematocrit level 30%, abnormal ECG characteristics, shortness of breath, and triage systolic blood pressure 90 mm Hg), and outcomes (as per the original study) were extracted. Results: Of 915 visits screened, 505 were included. Forty-nine (9.7%) visits were associated with serious outcomes. The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%). Including monitor abnormalities in the ECG variable would improve sensitivity to 96% (47/49 outcomes; 95% CI 87% to 99%). Although physicians failed to predict 2 deaths, the rule would have predicted all 3 deaths that occurred after ED discharge. Implementing the rule in our setting would increase the admission rate from 12.3% to 69.5%. Conclusion: In this retrospective Canadian study, the San Francisco Syncope Rule performed with comparable sensitivity but significantly poorer specificity than previously reported. Implementing the rule would significantly increase admission rates. Further studies to either refine the San Francisco Syncope Rule or develop a new rule are needed.

Original languageEnglish
Pages (from-to)464-472
Number of pages9
JournalAnnals of Emergency Medicine
Volume55
Issue number5
DOIs
Publication statusPublished - May 2010

Fingerprint

San Francisco
Syncope
Hospital Emergency Service
Confidence Intervals
Electrocardiography
Blood Pressure
Physicians
Unconsciousness
Triage
Street Drugs
Tertiary Healthcare
Craniocerebral Trauma
Hematocrit
Dyspnea
Seizures
Emergencies
Heart Failure
Retrospective Studies
Alcohols

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Thiruganasambandamoorthy, V., Hess, E. P., Alreesi, A., Perry, J. J., Wells, G. A., & Stiell, I. G. (2010). External validation of the San Francisco syncope rule in the Canadian setting. Annals of Emergency Medicine, 55(5), 464-472. https://doi.org/10.1016/j.annemergmed.2009.10.001

External validation of the San Francisco syncope rule in the Canadian setting. / Thiruganasambandamoorthy, Venkatesh; Hess, Erik P.; Alreesi, Abdullah; Perry, Jeffrey J.; Wells, George A.; Stiell, Ian G.

In: Annals of Emergency Medicine, Vol. 55, No. 5, 05.2010, p. 464-472.

Research output: Contribution to journalReview article

Thiruganasambandamoorthy, V, Hess, EP, Alreesi, A, Perry, JJ, Wells, GA & Stiell, IG 2010, 'External validation of the San Francisco syncope rule in the Canadian setting', Annals of Emergency Medicine, vol. 55, no. 5, pp. 464-472. https://doi.org/10.1016/j.annemergmed.2009.10.001
Thiruganasambandamoorthy, Venkatesh ; Hess, Erik P. ; Alreesi, Abdullah ; Perry, Jeffrey J. ; Wells, George A. ; Stiell, Ian G. / External validation of the San Francisco syncope rule in the Canadian setting. In: Annals of Emergency Medicine. 2010 ; Vol. 55, No. 5. pp. 464-472.
@article{d6ab39279cf74b329925e95e0ab089d9,
title = "External validation of the San Francisco syncope rule in the Canadian setting",
abstract = "Study objective: Syncope is a common disposition challenge for emergency physicians. Among the riskstratification instruments available, only the San Francisco Syncope Rule is rigorously developed. We evaluate its performance in Canadian emergency department (ED) syncope patients. Methods: This retrospective review included patients aged 16 years or older who fulfilled the definition of syncope (transient loss of consciousness with complete recovery) and presented to a tertiary care ED during an 18-month period. We excluded patients with ongoing altered mental status, alcohol/illicit drug use, seizure, and head and severe trauma. Patient characteristics, 5 predictors for the rule (history of congestive heart failure, hematocrit level 30{\%}, abnormal ECG characteristics, shortness of breath, and triage systolic blood pressure 90 mm Hg), and outcomes (as per the original study) were extracted. Results: Of 915 visits screened, 505 were included. Forty-nine (9.7{\%}) visits were associated with serious outcomes. The rule performed with a sensitivity of 90{\%} (44/49 outcomes; 95{\%} confidence interval [CI] 79{\%} to 96{\%}) and a specificity of 33{\%} (95{\%} CI 32{\%} to 34{\%}). Including monitor abnormalities in the ECG variable would improve sensitivity to 96{\%} (47/49 outcomes; 95{\%} CI 87{\%} to 99{\%}). Although physicians failed to predict 2 deaths, the rule would have predicted all 3 deaths that occurred after ED discharge. Implementing the rule in our setting would increase the admission rate from 12.3{\%} to 69.5{\%}. Conclusion: In this retrospective Canadian study, the San Francisco Syncope Rule performed with comparable sensitivity but significantly poorer specificity than previously reported. Implementing the rule would significantly increase admission rates. Further studies to either refine the San Francisco Syncope Rule or develop a new rule are needed.",
author = "Venkatesh Thiruganasambandamoorthy and Hess, {Erik P.} and Abdullah Alreesi and Perry, {Jeffrey J.} and Wells, {George A.} and Stiell, {Ian G.}",
year = "2010",
month = "5",
doi = "10.1016/j.annemergmed.2009.10.001",
language = "English",
volume = "55",
pages = "464--472",
journal = "Annals of Emergency Medicine",
issn = "0196-0644",
publisher = "Mosby Inc.",
number = "5",

}

TY - JOUR

T1 - External validation of the San Francisco syncope rule in the Canadian setting

AU - Thiruganasambandamoorthy, Venkatesh

AU - Hess, Erik P.

AU - Alreesi, Abdullah

AU - Perry, Jeffrey J.

AU - Wells, George A.

AU - Stiell, Ian G.

PY - 2010/5

Y1 - 2010/5

N2 - Study objective: Syncope is a common disposition challenge for emergency physicians. Among the riskstratification instruments available, only the San Francisco Syncope Rule is rigorously developed. We evaluate its performance in Canadian emergency department (ED) syncope patients. Methods: This retrospective review included patients aged 16 years or older who fulfilled the definition of syncope (transient loss of consciousness with complete recovery) and presented to a tertiary care ED during an 18-month period. We excluded patients with ongoing altered mental status, alcohol/illicit drug use, seizure, and head and severe trauma. Patient characteristics, 5 predictors for the rule (history of congestive heart failure, hematocrit level 30%, abnormal ECG characteristics, shortness of breath, and triage systolic blood pressure 90 mm Hg), and outcomes (as per the original study) were extracted. Results: Of 915 visits screened, 505 were included. Forty-nine (9.7%) visits were associated with serious outcomes. The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%). Including monitor abnormalities in the ECG variable would improve sensitivity to 96% (47/49 outcomes; 95% CI 87% to 99%). Although physicians failed to predict 2 deaths, the rule would have predicted all 3 deaths that occurred after ED discharge. Implementing the rule in our setting would increase the admission rate from 12.3% to 69.5%. Conclusion: In this retrospective Canadian study, the San Francisco Syncope Rule performed with comparable sensitivity but significantly poorer specificity than previously reported. Implementing the rule would significantly increase admission rates. Further studies to either refine the San Francisco Syncope Rule or develop a new rule are needed.

AB - Study objective: Syncope is a common disposition challenge for emergency physicians. Among the riskstratification instruments available, only the San Francisco Syncope Rule is rigorously developed. We evaluate its performance in Canadian emergency department (ED) syncope patients. Methods: This retrospective review included patients aged 16 years or older who fulfilled the definition of syncope (transient loss of consciousness with complete recovery) and presented to a tertiary care ED during an 18-month period. We excluded patients with ongoing altered mental status, alcohol/illicit drug use, seizure, and head and severe trauma. Patient characteristics, 5 predictors for the rule (history of congestive heart failure, hematocrit level 30%, abnormal ECG characteristics, shortness of breath, and triage systolic blood pressure 90 mm Hg), and outcomes (as per the original study) were extracted. Results: Of 915 visits screened, 505 were included. Forty-nine (9.7%) visits were associated with serious outcomes. The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%). Including monitor abnormalities in the ECG variable would improve sensitivity to 96% (47/49 outcomes; 95% CI 87% to 99%). Although physicians failed to predict 2 deaths, the rule would have predicted all 3 deaths that occurred after ED discharge. Implementing the rule in our setting would increase the admission rate from 12.3% to 69.5%. Conclusion: In this retrospective Canadian study, the San Francisco Syncope Rule performed with comparable sensitivity but significantly poorer specificity than previously reported. Implementing the rule would significantly increase admission rates. Further studies to either refine the San Francisco Syncope Rule or develop a new rule are needed.

UR - http://www.scopus.com/inward/record.url?scp=77951883787&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=77951883787&partnerID=8YFLogxK

U2 - 10.1016/j.annemergmed.2009.10.001

DO - 10.1016/j.annemergmed.2009.10.001

M3 - Review article

C2 - 19944489

AN - SCOPUS:77951883787

VL - 55

SP - 464

EP - 472

JO - Annals of Emergency Medicine

JF - Annals of Emergency Medicine

SN - 0196-0644

IS - 5

ER -