title: Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope.
abstract: BACKGROUND
  Syncope can be caused by serious conditions not evident during initial evaluation, which can lead to serious adverse events, including death, after disposition from the emergency department. We sought to develop a clinical decision tool to identify adult patients with syncope who are at risk of a serious adverse event within 30 days after disposition from the emergency department.
  
  
  METHODS
  We prospectively enrolled adults (age ≥ 16 yr) with syncope who presented within 24 hours after the event to 1 of 6 large emergency departments from Sept. 29, 2010, to Feb. 27, 2014. We collected standardized variables at index presentation from clinical evaluation and investigations. Adjudicated serious adverse events included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, serious hemorrhage and procedural interventions within 30 days.
  
  
  RESULTS
  We enrolled 4030 patients with syncope; the mean age was 53.6 years, 55.5% were women, and 9.5% were admitted to hospital. Serious adverse events occurred in 147 (3.6%) of the patients within 30 days after disposition from the emergency department. Of 43 candidate predictors examined, we included 9 in the final model: predisposition to vasovagal syncope, heart disease, any systolic pressure reading in the emergency department < 90 or > 180 mm Hg, troponin level above 99th percentile for the normal population, abnormal QRS axis (< -30° or > 100°), QRS duration longer than 130 ms, QTc interval longer than 480 ms, emergency department diagnosis of cardiac syncope and emergency department diagnosis of vasovagal syncope (C statistic 0.88, 95% confidence interval [CI] 0.85-0.90; optimism 0.015; goodness-of-fit p = 0.11). The risk of a serious adverse event within 30 days ranged from 0.4% for a score of -3 to 83.6% for a score of 11. The sensitivity was 99.2% (95% CI 95.9%-100%) for a threshold score of -2 or higher and 97.7% (95% CI 93.5%-99.5%) for a threshold score of -1 or higher.
  
  
  CONCLUSIONS
  The Canadian Syncope Risk Score showed good discrimination and calibration for 30-day risk of serious adverse events after disposition from the emergency department. Once validated, the tool will be able to accurately stratify the risk of serious adverse events among patients presenting with syncope, including those at low risk who can be discharged home quickly.
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta. vthirug@ohri.ca.
authors.forename: Venkatesh
authors.initials: V
authors.lastname: Thiruganasambandamoorthy
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Kwong
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: George A
authors.initials: GA
authors.lastname: Wells
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Marco L A
authors.initials: MLA
authors.lastname: Sivilotti
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Mukarram
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Brian H
authors.initials: BH
authors.lastname: Rowe
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Eddy
authors.initials: E
authors.lastname: Lang
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Perry
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Robert
authors.initials: R
authors.lastname: Sheldon
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
authors.affiliation: Departments of Emergency Medicine (Thiruganasambandamoorthy, Perry, Stiell) and of Epidemiology and Community Medicine (Thiruganasambandamoorthy, Kwong, Wells, Perry, Stiell, Taljaard), University of Ottawa; Ottawa Hospital Research Institute (Thiruganasambandamoorthy, Kwong, Mukarram, Perry, Stiell, Taljaard), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and of Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Departments of Emergency Medicine (Lang) and Medicine (Sheldon), University of Calgary, Calgary, Alta.
authors.forename: Monica
authors.initials: M
authors.lastname: Taljaard
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001145:Arrhythmias, Cardiac / Q000453:epidemiology*; D002170:Canada; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000453:epidemiology; D010351:Patient Discharge; D011379:Prognosis; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000453:epidemiology*; D018570:Risk Assessment; D012307:Risk Factors; D013575:Syncope / Q000150:complications* / Q000175:diagnosis*; D055815:Young Adult