Skip to main content
PMC home page
Emergency Medicine Journal : EMJ logoLink to Emergency Medicine Journal : EMJ
. 2002 Jan;19(1):23–27. doi: 10.1136/emj.19.1.23

Risk stratification of patients with syncope in an accident and emergency department

S Crane 1
PMCID: PMC1725786  PMID: 11777866

Abstract

Objectives: This study categorised syncopal patients, in a British accident and emergency (A&E) department, into three prognostic groups, using American College of Physicians (ACP) guidelines. The one year mortality of the three groups was studied to see if risk stratification using these guidelines is applicable to these patients and also whether admission improved outcome.

Methods: The records of all syncopal patients presenting to the Leeds General Infirmary A&E department during an eight week period from 2 November 1998 were identified. The cohort was grouped according to ACP guidelines into those who had an absolute indication for admission (group 1), a probable indication for admission (group 2) and no indication for admission (group 3). The actual disposal was recorded and for each patient mortality data were retrieved from general practices or health authorities one year later. The three groups were compared.

Results: Two hundred and ten records (1.7% of all new patients aged 16 years or above) were analysed. Forty per cent of the cohort were not assigned a diagnosis after their assessment in A&E. Forty seven (22%) were placed in ACP group 1, 63 (30%) in ACP group 2 and 100 (48%) in ACP group 3. Thirty six per cent of those in group 1 had died within a year, 14% of those in group 2 and none of those in group 3. In neither group 1 patients ("high risk") nor group 2 patients ("moderate risk") did admission to the hospital seem to influence outcome. However, three patients died within a week of their presentation, and two of them had been discharged from A&E.

Conclusion: It is possible to stratify syncopal patients presenting acutely to A&E, according to prognosis, using ACP guidelines. Disposal decisions for these patients should be based on their apparent prognosis (as defined in the ACP guidelines) and not on the diagnosis, which is often difficult to make.

Full Text

The Full Text of this article is available as a PDF (120.2 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Atkins D., Hanusa B., Sefcik T., Kapoor W. Syncope and orthostatic hypotension. Am J Med. 1991 Aug;91(2):179–185. doi: 10.1016/0002-9343(91)90012-m. [DOI] [PubMed] [Google Scholar]
  2. Bachinsky W. B., Linzer M., Weld L., Estes N. A., 3rd Usefulness of clinical characteristics in predicting the outcome of electrophysiologic studies in unexplained syncope. Am J Cardiol. 1992 Apr 15;69(12):1044–1049. doi: 10.1016/0002-9149(92)90861-r. [DOI] [PubMed] [Google Scholar]
  3. Day S. C., Cook E. F., Funkenstein H., Goldman L. Evaluation and outcome of emergency room patients with transient loss of consciousness. Am J Med. 1982 Jul;73(1):15–23. doi: 10.1016/0002-9343(82)90913-5. [DOI] [PubMed] [Google Scholar]
  4. Denes P., Uretz E., Ezri M. D., Borbola J. Clinical predictors of electrophysiologic findings in patients with syncope of unknown origin. Arch Intern Med. 1988 Sep;148(9):1922–1928. [PubMed] [Google Scholar]
  5. Eagle K. A., Black H. R., Cook E. F., Goldman L. Evaluation of prognostic classifications for patients with syncope. Am J Med. 1985 Oct;79(4):455–460. doi: 10.1016/0002-9343(85)90032-4. [DOI] [PubMed] [Google Scholar]
  6. Georgeson S., Linzer M., Griffith J. L., Weld L., Selker H. P. Acute cardiac ischemia in patients with syncope: importance of the initial electrocardiogram. J Gen Intern Med. 1992 Jul-Aug;7(4):379–386. doi: 10.1007/BF02599151. [DOI] [PubMed] [Google Scholar]
  7. Hayes O. W. Evaluation of syncope in the emergency department. Emerg Med Clin North Am. 1998 Aug;16(3):601-15, viii. doi: 10.1016/s0733-8627(05)70020-1. [DOI] [PubMed] [Google Scholar]
  8. Kapoor W. N. Evaluation and management of the patient with syncope. JAMA. 1992 Nov 11;268(18):2553–2560. [PubMed] [Google Scholar]
  9. Kapoor W. N. Evaluation and outcome of patients with syncope. Medicine (Baltimore) 1990 May;69(3):160–175. doi: 10.1097/00005792-199005000-00004. [DOI] [PubMed] [Google Scholar]
  10. Kapoor W. N., Hanusa B. H. Is syncope a risk factor for poor outcomes? Comparison of patients with and without syncope. Am J Med. 1996 Jun;100(6):646–655. doi: 10.1016/s0002-9343(95)00052-6. [DOI] [PubMed] [Google Scholar]
  11. Kapoor W. N., Karpf M., Wieand S., Peterson J. R., Levey G. S. A prospective evaluation and follow-up of patients with syncope. N Engl J Med. 1983 Jul 28;309(4):197–204. doi: 10.1056/NEJM198307283090401. [DOI] [PubMed] [Google Scholar]
  12. Koziol-McLain J., Lowenstein S. R., Fuller B. Orthostatic vital signs in emergency department patients. Ann Emerg Med. 1991 Jun;20(6):606–610. doi: 10.1016/s0196-0644(05)82376-5. [DOI] [PubMed] [Google Scholar]
  13. Krol R. B., Morady F., Flaker G. C., DiCarlo L. A., Jr, Baerman J. M., Hewett J., de Buitleir M. Electrophysiologic testing in patients with unexplained syncope: clinical and noninvasive predictors of outcome. J Am Coll Cardiol. 1987 Aug;10(2):358–363. doi: 10.1016/s0735-1097(87)80019-0. [DOI] [PubMed] [Google Scholar]
  14. Linzer M., Yang E. H., Estes N. A., 3rd, Wang P., Vorperian V. R., Kapoor W. N. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997 Jun 15;126(12):989–996. doi: 10.7326/0003-4819-126-12-199706150-00012. [DOI] [PubMed] [Google Scholar]
  15. Linzer M., Yang E. H., Estes N. A., 3rd, Wang P., Vorperian V. R., Kapoor W. N. Diagnosing syncope. Part 2: Unexplained syncope. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997 Jul 1;127(1):76–86. doi: 10.7326/0003-4819-127-1-199707010-00014. [DOI] [PubMed] [Google Scholar]
  16. Lipsitz L. A., Wei J. Y., Rowe J. W. Syncope in an elderly, institutionalised population: prevalence, incidence, and associated risk. Q J Med. 1985 Apr;55(216):45–54. [PubMed] [Google Scholar]
  17. Martin G. J., Adams S. L., Martin H. G., Mathews J., Zull D., Scanlon P. J. Prospective evaluation of syncope. Ann Emerg Med. 1984 Jul;13(7):499–504. doi: 10.1016/s0196-0644(84)80511-9. [DOI] [PubMed] [Google Scholar]
  18. Martin T. P., Hanusa B. H., Kapoor W. N. Risk stratification of patients with syncope. Ann Emerg Med. 1997 Apr;29(4):459–466. doi: 10.1016/s0196-0644(97)70217-8. [DOI] [PubMed] [Google Scholar]
  19. McIntosh S., Da Costa D., Kenny R. A. Outcome of an integrated approach to the investigation of dizziness, falls and syncope in elderly patients referred to a 'syncope' clinic. Age Ageing. 1993 Jan;22(1):53–58. doi: 10.1093/ageing/22.1.53. [DOI] [PubMed] [Google Scholar]
  20. McLaren A. J., Lear J., Daniels R. G. Collapse in an accident and emergency department. J R Soc Med. 1994 Mar;87(3):138–139. doi: 10.1177/014107689408700307. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Middlekauff H. R., Stevenson W. G., Saxon L. A. Prognosis after syncope: impact of left ventricular function. Am Heart J. 1993 Jan;125(1):121–127. doi: 10.1016/0002-8703(93)90064-g. [DOI] [PubMed] [Google Scholar]
  22. Middlekauff H. R., Stevenson W. G., Stevenson L. W., Saxon L. A. Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. J Am Coll Cardiol. 1993 Jan;21(1):110–116. doi: 10.1016/0735-1097(93)90724-f. [DOI] [PubMed] [Google Scholar]
  23. Moazez F., Peter T., Simonson J., Mandel W. J., Vaughn C., Gang E. Syncope of unknown origin: clinical, noninvasive, and electrophysiologic determinants of arrhythmia induction and symptom recurrence during long-term follow-up. Am Heart J. 1991 Jan;121(1 Pt 1):81–88. doi: 10.1016/0002-8703(91)90959-l. [DOI] [PubMed] [Google Scholar]
  24. Silverstein M. D., Singer D. E., Mulley A. G., Thibault G. E., Barnett G. O. Patients with syncope admitted to medical intensive care units. JAMA. 1982 Sep 10;248(10):1185–1189. [PubMed] [Google Scholar]

Articles from Emergency Medicine Journal : EMJ are provided here courtesy of BMJ Publishing Group

RESOURCES