EBQ:San Francisco Syncope Rule: Difference between revisions
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| fulltexturl= http://www.sciencedirect.com.journals.labiomed.org/science/article/pii/S0196064405019591 | | fulltexturl= http://www.sciencedirect.com.journals.labiomed.org/science/article/pii/S0196064405019591 | ||
| pdfurl=http://theddx.org/papers/San_Francisco_syncope.pdf | | pdfurl=http://theddx.org/papers/San_Francisco_syncope.pdf | ||
| status= | | status=Complete | ||
}} | }} | ||
==Clinical Question== | ==Clinical Question== | ||
Line 19: | Line 19: | ||
==Conclusion== | ==Conclusion== | ||
*The San Francisco Syncope Rule demonstrated to be highly sensitive (98% sensitivity, 95% CI 89-100%) but not very specific (56%, 95% CI 52-60%) for predicting serious outcomes. | |||
==Major Points== | ==Major Points== | ||
{{San Francisco Syncope Rule}} | {{San Francisco Syncope Rule}} | ||
The rule is positive if any of the above apply to the patient. | |||
==Study Design== | ==Study Design== | ||
*A prospective cohort study | |||
*N =: 760 patients had 791 visits for syncope (1.2% of all ED visits) | |||
*Consecutive patients with syncope or near syncope presenting to an emergency department of a large, urban teaching hospital were identified and enrolled from July 15, 2002 to August 31, 2004 | |||
*Physicians prospectively applied the San Francisco Syncope Rule | |||
**Patient follow up performed to determine if the patient suffered a predefined serious outcome within 30 days of their ED visit | |||
**Physicians completed a short Web-based form and enrolled patients after their assessment | |||
**Study investigators reviewed all data forms in order to ensure the correct interpretation of the rule | |||
*30 day follow-up completed after patients' index ED visit to determine short-term outcomes that would require admission | |||
**Short-term serious outcomes defined as: | |||
***Death | |||
***Myocardial Infarction | |||
****Any elevation of troponin or ECG change with an accompanying diagnosis of myocardial infarction on D/C and confirmed by the cardiology service or primary physician | |||
***Arrhythmia | |||
***Pulmonary Embolism | |||
****Needed to have received treatment for the pulmonary embolism or had it confirmed on autopsy | |||
***Stoke | |||
***Subarachnoid Hemorrhage | |||
***Significant Hemorrhage or Anemia Requiring Transfusion | |||
***Procedural intervention to treat a related cause of syncope or any condition causing or likely to cause a return ED visit | |||
***Hospitalization for a related event | |||
==Population== | ==Population== | ||
===Patient Demographics=== | ===Patient Demographics=== | ||
*364 men, 427 females | |||
*Mean age: 61 | |||
*Admitted: 469 (59%) | |||
*Patients with serious outcomes after ED visit: 54 (6.8%) | |||
**Death: 3 | |||
**Arrhythmia: 23 | |||
**Myocardial Infarction: 11 | |||
**Valvular Heart Disease: 1 | |||
**Significant Hemorrhage: 7 | |||
**TIA/Stroke: 3 | |||
**Sepsis: 3 | |||
**Admission after ED Discharge : 3 | |||
===Inclusion Criteria=== | ===Inclusion Criteria=== | ||
*Consecutive patients presenting with syncope or near syncope without any of the predefined exclusion criteria | |||
===Exclusion Criteria=== | ===Exclusion Criteria=== | ||
*Trauma-related loss of consciousness | |||
*Alcohol-related loss of consciousness | |||
*Drug-related loss of consciousness | |||
*Definite seizure | |||
*LOC associated with an altered level of consciousness or persistent new neurologic deficits did not meet operational definition of syncope and were excluded | |||
==Interventions== | ==Interventions== | ||
==Outcomes== | ==Outcomes== | ||
*30 day follow-up after the patients' index ED visit to determine serious short-term outcomes | |||
*Serious short-term outcomes defined as: death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage or anemia requiring transfusion, procedural intervention to treat a related cause of syncope or any condition likely to cause a return ED visit, and hospitalization for a related event | |||
===Primary Outcome=== | ===Primary Outcome=== | ||
*Patients with serious outcomes after ED visit: 54 (6.8%) | |||
'''Performance of the San Francisco Syncope Rule in the validation cohort''' | |||
{| class="wikitable" | |||
|- | |||
! Decision Rule !! Yes !! No | |||
|- | |||
| Rule Positive || 52 || 290 | |||
|- | |||
| Rule Negative || 1 || 370 | |||
|} | |||
*Sensitivity 98% (95% CI 89% to 100%) | |||
*Specificity 56% (95% CI 52% to 60%) | |||
*Negative Predictive Value 99.7% (95% CI 98% to 100%) | |||
*Positive Predictive Value 15% (95% CI 12% to 20%) | |||
*Death: 3 | |||
*Arrhythmia: 23 | |||
*Myocardial Infarction: 11 | |||
*Valvular Heart Disease: 1 | |||
*Significant Hemorrhage: 7 | |||
*TIA/Stroke: 3 | |||
*Sepsis: 3 | |||
*Admission after ED discharge: 3 | |||
===Secondary Outcomes=== | ===Secondary Outcomes=== | ||
*Physicians accurately interpreted the rule 95% of the time | |||
**Physicians felt comfortable using the rule in 79% of the cases | |||
**Physicians felt neutral using the rule in 15% of cases | |||
**Physicians felt uncomfortable using the rule in 6% of cases | |||
*The San Francisco Syncope Rule would have classified 52% of the patients as high risk | |||
**Using the rule potentially would have decreased overall admissions by 7% | |||
**Applying the rule to only the 453 patients admitted might have decreased admissions by 24% | |||
===Subgroup analysis=== | ===Subgroup analysis=== | ||
==Criticisms & Further Discussion== | ==Criticisms & Further Discussion== | ||
*Patients from only one hospital enrolled in the study | |||
*Validation study is performed at the same center used to derive the original rule | |||
*Wide margin of error observed in sensitivity<ref>Miller C, Hoekstra J. Prospective Validation of the San Francisco Syncope Rule: Will It Change Practice? Ann Emerg Med. 2006 May;47(5):455-56. PubMed PMID: 16631986</ref> | |||
**98% [95% confidence interval 89% to 100%). Taking the lower limit of the confidence interval as the correct value, the clinical decision rule cannot be considered highly sensitive | |||
***For example, in 100 patients with syncope of undetermined cause on presentation, 11 discharged home could have an adverse outcome | |||
*54 patients has serious outcomes, but only 53 patients had data forms prospectively completed. The patient without a data form was excluded from the sensitivity analysis | |||
==Funding== | |||
*A career development grant from the National Institutes of Health available to Dr. James Quinn, MD, MS, primary investigator of the study | |||
==Further Reading== | |||
[http://www.acep.org/Clinical---Practice-Management/Clinical-Policy--Management-of-Syncope/ ACEP Clinical Practice Management: Management of Syncope] | |||
{{JC info | |||
| title= Risk stratification of patients with syncope | |||
| abbreviation= | |||
| expansion= | |||
| published= | |||
| author= Martin TP et al. | |||
| journal= Ann Emerg Med | |||
| year= 1997 | |||
| volume= 29 | |||
| issue= | |||
| pages= 459-466 | |||
| pmid= 9095005 | |||
| fulltexturl= | |||
| pdfurl= | |||
| status=Complete | |||
}} | |||
{{JC info | |||
| title= Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score | |||
| abbreviation= | |||
| expansion= | |||
| published= | |||
| author= Colivicchi F et al | |||
| journal= Eur Heart J. | |||
| year= 2003 | |||
| volume= 24 | |||
| issue= | |||
| pages= 811-819 | |||
| pmid= 12727148 | |||
| fulltexturl= | |||
| pdfurl= | |||
| status=Complete | |||
}} | |||
{{JC info | |||
| title= A risk score to predict arrhythmias in patients with unexplained syncope | |||
| abbreviation= | |||
| expansion= | |||
| published= | |||
| author= Sarasin FP, Hanusa BH, Perneger T, et al. | |||
| journal= Acad Emerg Med | |||
| year= 2003 | |||
| volume= 10 | |||
| issue= | |||
| pages= 1312-1317 | |||
| pmid= 14644781 | |||
| fulltexturl= | |||
| pdfurl= | |||
| status=Complete | |||
}} | |||
== | ==See Also== | ||
*[[Syncope]] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:EBQ]] | [[Category:EBQ]] | ||
[[Category: | [[Category:Neurology]] | ||
[[Category: | [[Category:Cardiology]] |
Latest revision as of 14:14, 22 March 2016
Complete Journal Club Article
Quinn J. et al.. "Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes". Ann Emerg Med. 2006. 31(26):2992-6.
PubMed Full text PDF
PubMed Full text PDF
Clinical Question
Can the San Francisco Syncope Rule be used in clinical practice to risk stratify patients presenting with syncope?
Conclusion
- The San Francisco Syncope Rule demonstrated to be highly sensitive (98% sensitivity, 95% CI 89-100%) but not very specific (56%, 95% CI 52-60%) for predicting serious outcomes.
Major Points
- Criteria (CHESS Pneumonic)[1]
- CHF History
- Hct < 30%
- ECG Abnormality
- SOB history
- SBP < 90mmHg at triage
The rule is positive if any of the above apply to the patient.
Study Design
- A prospective cohort study
- N =: 760 patients had 791 visits for syncope (1.2% of all ED visits)
- Consecutive patients with syncope or near syncope presenting to an emergency department of a large, urban teaching hospital were identified and enrolled from July 15, 2002 to August 31, 2004
- Physicians prospectively applied the San Francisco Syncope Rule
- Patient follow up performed to determine if the patient suffered a predefined serious outcome within 30 days of their ED visit
- Physicians completed a short Web-based form and enrolled patients after their assessment
- Study investigators reviewed all data forms in order to ensure the correct interpretation of the rule
- 30 day follow-up completed after patients' index ED visit to determine short-term outcomes that would require admission
- Short-term serious outcomes defined as:
- Death
- Myocardial Infarction
- Any elevation of troponin or ECG change with an accompanying diagnosis of myocardial infarction on D/C and confirmed by the cardiology service or primary physician
- Arrhythmia
- Pulmonary Embolism
- Needed to have received treatment for the pulmonary embolism or had it confirmed on autopsy
- Stoke
- Subarachnoid Hemorrhage
- Significant Hemorrhage or Anemia Requiring Transfusion
- Procedural intervention to treat a related cause of syncope or any condition causing or likely to cause a return ED visit
- Hospitalization for a related event
- Short-term serious outcomes defined as:
Population
Patient Demographics
- 364 men, 427 females
- Mean age: 61
- Admitted: 469 (59%)
- Patients with serious outcomes after ED visit: 54 (6.8%)
- Death: 3
- Arrhythmia: 23
- Myocardial Infarction: 11
- Valvular Heart Disease: 1
- Significant Hemorrhage: 7
- TIA/Stroke: 3
- Sepsis: 3
- Admission after ED Discharge : 3
Inclusion Criteria
- Consecutive patients presenting with syncope or near syncope without any of the predefined exclusion criteria
Exclusion Criteria
- Trauma-related loss of consciousness
- Alcohol-related loss of consciousness
- Drug-related loss of consciousness
- Definite seizure
- LOC associated with an altered level of consciousness or persistent new neurologic deficits did not meet operational definition of syncope and were excluded
Interventions
Outcomes
- 30 day follow-up after the patients' index ED visit to determine serious short-term outcomes
- Serious short-term outcomes defined as: death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage or anemia requiring transfusion, procedural intervention to treat a related cause of syncope or any condition likely to cause a return ED visit, and hospitalization for a related event
Primary Outcome
- Patients with serious outcomes after ED visit: 54 (6.8%)
Performance of the San Francisco Syncope Rule in the validation cohort
Decision Rule | Yes | No |
---|---|---|
Rule Positive | 52 | 290 |
Rule Negative | 1 | 370 |
- Sensitivity 98% (95% CI 89% to 100%)
- Specificity 56% (95% CI 52% to 60%)
- Negative Predictive Value 99.7% (95% CI 98% to 100%)
- Positive Predictive Value 15% (95% CI 12% to 20%)
- Death: 3
- Arrhythmia: 23
- Myocardial Infarction: 11
- Valvular Heart Disease: 1
- Significant Hemorrhage: 7
- TIA/Stroke: 3
- Sepsis: 3
- Admission after ED discharge: 3
Secondary Outcomes
- Physicians accurately interpreted the rule 95% of the time
- Physicians felt comfortable using the rule in 79% of the cases
- Physicians felt neutral using the rule in 15% of cases
- Physicians felt uncomfortable using the rule in 6% of cases
- The San Francisco Syncope Rule would have classified 52% of the patients as high risk
- Using the rule potentially would have decreased overall admissions by 7%
- Applying the rule to only the 453 patients admitted might have decreased admissions by 24%
Subgroup analysis
Criticisms & Further Discussion
- Patients from only one hospital enrolled in the study
- Validation study is performed at the same center used to derive the original rule
- Wide margin of error observed in sensitivity[2]
- 98% [95% confidence interval 89% to 100%). Taking the lower limit of the confidence interval as the correct value, the clinical decision rule cannot be considered highly sensitive
- For example, in 100 patients with syncope of undetermined cause on presentation, 11 discharged home could have an adverse outcome
- 98% [95% confidence interval 89% to 100%). Taking the lower limit of the confidence interval as the correct value, the clinical decision rule cannot be considered highly sensitive
- 54 patients has serious outcomes, but only 53 patients had data forms prospectively completed. The patient without a data form was excluded from the sensitivity analysis
Funding
- A career development grant from the National Institutes of Health available to Dr. James Quinn, MD, MS, primary investigator of the study
Further Reading
ACEP Clinical Practice Management: Management of Syncope
Complete Journal Club Article
Martin TP et al.. "Risk stratification of patients with syncope". Ann Emerg Med. 1997. 29:459-466.
PubMed
PubMed
Complete Journal Club Article
Colivicchi F et al. "Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score". Eur Heart J.. 2003. 24:811-819.
PubMed
PubMed
Complete Journal Club Article
Sarasin FP, Hanusa BH, Perneger T, et al.. "A risk score to predict arrhythmias in patients with unexplained syncope". Acad Emerg Med. 2003. 10:1312-1317.
PubMed
PubMed
See Also
References
- ↑ Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006 May;47(5):448-54. PubMed PMID: 16631985.
- ↑ Miller C, Hoekstra J. Prospective Validation of the San Francisco Syncope Rule: Will It Change Practice? Ann Emerg Med. 2006 May;47(5):455-56. PubMed PMID: 16631986