title: Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis.
abstract: BACKGROUND
  There have been several attempts to derive syncope prediction tools to guide clinician decision-making. However, they have not been largely adopted, possibly because of their lack of sensitivity and specificity. We sought to externally validate the existing tools and to compare them with clinical judgment, using an individual patient data meta-analysis approach.
  
  
  METHODS
  Electronic databases, bibliographies, and experts in the field were screened to find all prospective studies enrolling consecutive subjects presenting with syncope to the emergency department. Prediction tools and clinical judgment were applied to all patients in each dataset. Serious outcomes and death were considered separately during emergency department stay and at 10 and 30 days after presenting syncope. Pooled sensitivities, specificities, likelihood ratios, and diagnostic odds ratios, with 95% confidence intervals, were calculated.
  
  
  RESULTS
  Thirteen potentially relevant papers were retrieved (11 authors). Six authors agreed to share individual patient data. In total, 3681 patients were included. Three prediction tools (Osservatorio Epidemiologico sulla Sincope del Lazio [OESIL], San Francisco Syncope Rule [SFSR], Evaluation of Guidelines in Syncope Study [EGSYS]) could be assessed by the available datasets. None of the evaluated prediction tools performed better than clinical judgment in identifying serious outcomes during emergency department stay, and at 10 and 30 days after syncope.
  
  
  CONCLUSIONS
  Despite the use of an individual patient data approach to reduce heterogeneity among studies, a large variability was still present. Current prediction tools did not show better sensitivity, specificity, or prognostic yield compared with clinical judgment in predicting short-term serious outcome after syncope. Our systematic review strengthens the evidence that current prediction tools should not be strictly used in clinical practice.
authors.affiliation: Medicina fisiopatologica, Dipartimento di Medicina Interna, Osp. L. Sacco, Milano, Italy. Electronic address: giorgic2@gmail.com.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Costantino
authors.affiliation: Dipartimento di Scienze Biomediche e Cliniche "L. Sacco" - Università degli Studi di Milano, Milano, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Casazza
authors.affiliation: Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Reed
authors.affiliation: Medicina fisiopatologica, Dipartimento di Medicina Interna, Osp. L. Sacco, Milano, Italy.
authors.forename: Ilaria
authors.initials: I
authors.lastname: Bossi
authors.affiliation: Department of Emergency Medicine, Oregon Health and Science University, Portland.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Sun
authors.affiliation: Electrophysiology Unit, Cardiology Division, Department of Medicine, Ospedale S. Giuseppe, Empoli, Italy.
authors.forename: Attilio
authors.initials: A
authors.lastname: Del Rosso
authors.affiliation: Syncope Unit, Geriatric Cardiology and Medicine, Azienda Ospedaliero Universitaria Careggi and University of Florence, Firenze, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ungar
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Shamai
authors.initials: S
authors.lastname: Grossman
authors.affiliation: Divisione di Cardiologia, Università degli Studi di Torino, Torino, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: D'Ascenzo
authors.affiliation: Division of Emergency Medicine, Stanford University School of Medicine, Calif.
authors.forename: James
authors.initials: J
authors.lastname: Quinn
authors.affiliation: Division of Emergency Medicine, University of California, San Francisco.
authors.forename: Daniel
authors.initials: D
authors.lastname: McDermott
authors.affiliation: Libin Cardiovascular Institute of Alberta, Calgary, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Sheldon
authors.affiliation: Internal Medicine, University of Milan, Humanitas Clinical and Research Center, Rozzano (MI), Italy.
authors.forename: Raffaello
authors.initials: R
authors.lastname: Furlan
mesh_terms: D003657:Decision Making; D004636:Emergency Service, Hospital; D006801:Humans; D007600:Judgment; D063868:Patient Outcome Assessment; D011379:Prognosis; D018570:Risk Assessment / Q000379:methods*; D012680:Sensitivity and Specificity; D013575:Syncope / Q000175:diagnosis* / Q000209:etiology
keywords: Individual patient data; Meta-analysis; Prognosis; Risk-stratification tools; Rules; Syncope