Accuracy and Quality of Clinical Decision Rules for Syncope in the Emergency Department: A Systematic Review and Meta-analysis

Abstract

Objectives We assessed the methodological quality and prognostic accuracy of clinical decision rules (CDR) in emergency department (ED) syncope patients. Methods We searched 5 electronic databases, reviewed reference lists of included studies and contacted content experts to identify articles for review. Studies that derived or validated CDRs in ED syncope patients were included. Two reviewers independently screened records for relevance, selected studies for inclusion, assessed study quality and abstracted data. Random effects meta-analysis was used to pool diagnostic performance estimates across studies that derived or validated the same CDR. Between study heterogeneity was assessed with I-squared statistic (I2), and subgroup hypotheses were tested using a test of interaction. Results We identified 18 eligible studies. Deficiencies in outcome (blinding) and inter-rater reliability assessment were the most common methodological weaknesses. Meta-analysis of the San Francisco Syncope Rule (SFSR) [sensitivity 86% (95%CI 83-89); specificity 49% (95%CI 48-51)] and the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score [sensitivity 95% (95%CI 88-98); specificity 31% (95%CI 29-34)]. Subgroup analysis identified study design [prospective, diagnostic odds ratio (DOR) 8.82 (95%CI 3.5-22) vs. retrospective, DOR 2.45 (95%CI 0.96-6.21)] and ECG determination [by evaluating physician, DOR 25.5 (95%CI 4.41-148) vs. researcher or cardiologist, DOR 4 (95%CI 2.15-7.55)] as potential explanations for the variability in SFSR performance. Conclusion The methodological quality and prognostic accuracy of CDRs for syncope is limited. Differences in study design and ECG interpretation may account for the variable prognostic performance of the SFSR when validated in different practice settings.

Causes and Predictors of 30‐Day Readmission in Patients With Syncope/Collapse: A Nationwide Cohort Study

“…Other models, such as the San Francisco Syncope Rule and Osservatorio Epidemiologico sulla Sincope nel Lazio scores, have been used to risk‐stratify patients for long‐term adverse outcomes. In one meta‐analysis, the sensitivity of the San Francisco Syncope Rule for predicting serious outcomes was 86% with a specificity of 49%, while the sensitivity of the Osservatorio Epidemiologico sulla Sincope nel Lazio score was 95% with a specificity of 31% 27. However, in a validation study, both scoring systems failed to flag the patients who were readmitted within 10 days (2/488 patients), and it should be noted that these scoring systems were validated as predictive of medium‐ and long‐term prognoses rather than short‐term outcomes 9, 27, 28, 29.…”

“…In one meta‐analysis, the sensitivity of the San Francisco Syncope Rule for predicting serious outcomes was 86% with a specificity of 49%, while the sensitivity of the Osservatorio Epidemiologico sulla Sincope nel Lazio score was 95% with a specificity of 31% 27. However, in a validation study, both scoring systems failed to flag the patients who were readmitted within 10 days (2/488 patients), and it should be noted that these scoring systems were validated as predictive of medium‐ and long‐term prognoses rather than short‐term outcomes 9, 27, 28, 29. Therefore, it should be taken into consideration that predictors of short‐term outcomes tend to differ from those of long‐term outcome, and these models would not be that helpful to risk‐stratify the patients for 30‐day readmission.…”

Syncope Risk Stratification in the Emergency Department

“…5,7,8,10,11 The primary goal of the ED physician is thus to discriminate individuals at low risk who can be safely discharged, from patients at high risk who require prompt hospitalization for monitoring and/or appropriate treatment.…”

“…Rules or risk scores may help the ED physician in decision making, although so far there is no compelling evidence that any score or rule performs better than personal clinical judgment in affecting patients' clinical outcomes. [10][11][12][13][14] …”

“…Because there is a low rate of adverse events following syncope, the risk scores and clinical rules are likely to better identify frailty than patients' short-term risk, which might account for the poor performance of the rule/ scores in identifying short-term adverse clinical outcomes. [10][11][12] Based on these considerations, the role of clinical decision rules or risk scores and their comparison with clinical judgment in the management of patients presenting in the ED for syncope remain to be elucidated. In addressing syncope, risk scores and decision rules can be useful by highlighting the critical variables that should be considered and we expect that the international single-patient meta-analysis currently in progress will provide a tentative answer to these issues.…”