Risk stratification of syncope: Current syncope guidelines and beyond

Abstract

Syncope is an alarming event carrying the possibility of serious outcomes, including sudden cardiac death (SCD). Therefore, immediate risk stratification should be applied whenever syncope occurs, especially in the Emergency Department, where most dramatic presentations occur. It has long been known that short-and long-term syncope prognosis is affected not only by its mechanism but also by presence of concomitant conditions, especially cardiovascular disease. Over the last two decades, several syncope prediction tools have been developed to refine patient stratification and triage patients who need expert in-hospital care from those who may receive nonurgent expert care in the community. However, despite promising results, prognostic tools for syncope remain challenging and often poorly effective.Current European Society of Cardiology syncope guidelines recommend an initial syncope workup based on detailed patient's history, physical examination supine and standing blood pressure, resting ECG, and laboratory tests, including cardiac biomarkers, where appropriate. Subsequent risk stratification based on screening of features aims to identify three groups: high-, intermediate-and low-risk. The first should immediately be hospitalized and appropriately investigated; intermediate group, with recurrent or medium-risk events, requires systematic evaluation by syncope experts; low-risk group, sporadic reflex syncope, merits education about its benign nature, and discharge. Thus, initial syncope risk stratification is crucial as it determines how and by whom syncope patients are managed. This review summarizes the crucial elements of syncope risk stratification, pros and cons of proposed risk evaluation scores, major challenges in initial syncope management, and how risk stratification impacts management of high-risk/recurrent syncope.

Trauma and syncope: looking beyond the injury

“…A 2022 literature review conducted by Sutton et al investigated the performance of syncope risk stratification tools available for use in the ED including the Martin-Kapoor score, the San Francesco Syncope Rule, the Osservatorio Epidemiologico sulla Sincope nel Lazio, the Risk Stratification of Syncope in the Emergency Department score, the Evaluation of Guidelines in Syncope Study score, the Boston Syncope Criteria, the Short-Term Prognosis of Syncope score, the FAINT score, the Basel IX ECG ALERT-CS tool, the Canadian Syncope Risk Score (CSRS), and the Early Standardised Clinical Judgement for syncope score (ESCJ). 36 All risk assessment tools employ a variety of factors including features from the history, examination, ECG, and serum biomarkers. Their findings suggest that the prognostic yield of most syncope risk stratification tools is no better than good clinical judgement.…”

“…When the cause of TLoC in the trauma patient remains unclear, risk stratification becomes necessary to guide accurate management. A 2022 literature review conducted by Sutton et al investigated the performance of syncope risk stratification tools available for use in the ED including the Martin-Kapoor score, the San Francesco Syncope Rule, the Osservatorio Epidemiologico sulla Sincope nel Lazio, the Risk Stratification of Syncope in the Emergency Department score, the Evaluation of Guidelines in Syncope Study score, the Boston Syncope Criteria, the Short-Term Prognosis of Syncope score, the FAINT score, the Basel IX ECG ALERT-CS tool, the Canadian Syncope Risk Score (CSRS), and the Early Standardised Clinical Judgement for syncope score (ESCJ) 36…”

Convulsive Syncope as a Complication of Outpatient Procedures: A Case Series and Review of the Literature

“…21 The ACC/AHA 2017 and European cardiologist 2018 guidelines agree that an abnormal physical examination including unstable vitals (persistent bradycardia ,40 and SBP ,90 mm Hg), the absence of prodromal symptoms, and an abnormal ECG identify a patient who is at high risk and must be immediately hospitalized. 22 Otherwise, if the ECG is normal and prodromal symptoms after an identifiable trigger were reported, assuming that the risk of underlying cardiovascular disease in the patient is low, the patient is likely exhibiting a self-limited convulsive syncope. 18 Under these circumstances, it is reasonable to take physical safety precautions such as laying the patient supine and having someone stay at the bedside.…”

Prevalence of and Variables Associated with Syncope-Related Injuries and Fractures in Germany: A Cross-Sectional Study in General Practices

“…Although syncope is often considered a benign clinical entity [ 1 , 8 , 9 , 10 ], it can be associated with significantly increased mortality [ 8 , 11 ] and significantly reduced quality of life (QoL) for those affected [ 12 , 13 , 14 , 15 ]. Further possible and potentially serious consequences of immediate syncopal loss of consciousness include resulting injuries and fractures [ 3 , 16 ], making the condition a significant public health issue.…”