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Outcomes in syncope research: a systematic review and critical appraisal

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Abstract

Syncope is the common clinical manifestation of different diseases, and this makes it difficult to define what outcomes should be considered in prognostic studies. The aim of this study is to critically analyze the outcomes considered in syncope studies through systematic review and expert consensus. We performed a systematic review of the literature to identify prospective studies enrolling consecutive patients presenting to the Emergency Department with syncope, with data on the characteristics and incidence of short-term outcomes. Then, the strengths and weaknesses of each outcome were discussed by international syncope experts to provide practical advice to improve future selection and assessment. 31 studies met our inclusion criteria. There is a high heterogeneity in both outcome choice and incidence between the included studies. The most commonly considered 7-day outcomes are mortality, dysrhythmias, myocardial infarction, stroke, and rehospitalisation. The most commonly considered 30-day outcomes are mortality, haemorrhage requiring blood transfusion, dysrhythmias, myocardial infarction, pacemaker or implantable defibrillator implantation, stroke, pulmonary embolism, and syncope relapse. We present a critical analysis of the pros and cons of the commonly considered outcomes, and provide possible solutions to improve their choice in ED syncope studies. We also support global initiatives to promote the standardization of patient management and data collection.

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References

  1. Moons KGM, Royston P, Vergouwe Y et al (2009) Prognosis and prognostic research: what, why, and how? BMJ 338:b375

    Article  PubMed  Google Scholar 

  2. Royston P, Moons KGM, Altman DG, Vergouwe Y (2009) Prognosis and prognostic research: developing a prognostic model. BMJ 338:b604

    Article  PubMed  Google Scholar 

  3. Moons KGM, Altman DG, Vergouwe Y, Royston P (2009) Prognosis and prognostic research: application and impact of prognostic models in clinical practice. BMJ 338:b606

    Article  PubMed  Google Scholar 

  4. D’Amico G, Malizia G, D’Amico M (2016) Prognosis research and risk of bias. Intern Emerg Med 11:251–260. https://doi.org/10.1007/s11739-016-1404-z

    Article  PubMed  Google Scholar 

  5. Moya A, Sutton R, Ammirati F et al (2009) Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 30:2631–2671

    Article  PubMed  PubMed Central  Google Scholar 

  6. Shen W-K, Sheldon RS, Benditt DG et al (2017) 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation. https://doi.org/10.1161/cir.0000000000000499

    Article  PubMed  Google Scholar 

  7. Costantino G, Sun BC, Barbic F et al (2016) Syncope clinical management in the Emergency Department: a consensus from the first international workshop on syncope risk stratification in the Emergency Department. Eur Heart J 37:1493–1498. https://doi.org/10.1093/eurheartj/ehv378

    Article  PubMed  Google Scholar 

  8. Sun BC, Costantino G, Barbic F et al (2014) Priorities for Emergency Department syncope research. Ann Emerg Med 64(649–655):e2. https://doi.org/10.1016/j.annemergmed.2014.04.014

    Article  Google Scholar 

  9. Sun BC, Thiruganasambandamoorthy V, Cruz JD (2012) Standardized reporting guidelines for Emergency Department syncope risk-stratification research. Acad Emerg Med 19:694–702

    Article  PubMed  PubMed Central  Google Scholar 

  10. Williamson C, Reed MJ (2015) Syncope: the Emergency Department and beyond. Intern Emerg Med 10:843–850. https://doi.org/10.1007/s11739-015-1298-1

    Article  PubMed  Google Scholar 

  11. Aziz EF, Pamidimukala CK, Bastawrose JH et al (2012) Short and long term outcomes of patients admitted with unexplained syncope using a simple novel self-pathway. Circ Cardiovasc Qual Outcomes 5(Suppl 1):A225

    Google Scholar 

  12. Birnbaum A, Esses D, Bijur P et al (2008) Failure to validate the San Francisco Syncope Rule in an independent Emergency Department population. Ann Emerg Med 52:151–159. https://doi.org/10.1016/j.annemergmed.2007.12.007

    Article  PubMed  Google Scholar 

  13. Cosgriff TM, Kelly A-M, Kerr D (2007) External validation of the San Francisco Syncope Rule in the Australian context. CJEM 9:157–161

    Article  PubMed  Google Scholar 

  14. Costantino G, Perego F, Dipaola F et al (2008) Short- and long-term prognosis of syncope, risk factors, and role of hospital admission: results from the STePS (Short-Term Prognosis of Syncope) study. J Am Coll Cardiol 51:276–283. https://doi.org/10.1016/j.jacc.2007.08.059

    Article  PubMed  Google Scholar 

  15. Crane SD (2002) Risk stratification of patients with syncope in an accident and Emergency Department. Emerg Med J 19:23–27

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  16. Day SC, Cook EF, Funkenstein H, Goldman L (1982) Evaluation and outcome of emergency room patients with transient loss of consciousness. Am J Med 73:15–23

    Article  PubMed  CAS  Google Scholar 

  17. Gomes DG, Kus T, Sant’anna RT et al (2016) Simple risk stratification score for prognosis of syncope. J Interv Card Electrophysiol 47:153–161. https://doi.org/10.1007/s10840-016-0165-y

    Article  PubMed  Google Scholar 

  18. Greve Y, Geier F, Popp S et al (2014) The prevalence and prognostic significance of near syncope and syncope: a prospective study of 395 cases in an Emergency Department (the SPEED study). Dtsch Arztebl Int 111:197–204. https://doi.org/10.3238/arztebl.2014.0197

    Article  PubMed  PubMed Central  Google Scholar 

  19. Grossman SA, Chiu D, Lipsitz L et al (2014) Can elderly patients without risk factors be discharged home when presenting to the Emergency Department with syncope? Arch Gerontol Geriatr 58:110–114

    Article  PubMed  Google Scholar 

  20. Grossman SA, Fischer C, Lipsitz LA et al (2007) Predicting adverse outcomes in syncope. J Emerg Med 33:233–239

    Article  PubMed  PubMed Central  Google Scholar 

  21. Grossman SA, Babineau M, Burke L et al (2012) Do outcomes of near syncope parallel syncope? Am J Emerg Med 30:203–206. https://doi.org/10.1016/j.ajem.2010.11.001

    Article  PubMed  Google Scholar 

  22. Guillermo M, Vargas D (2015) Validation of the san francisco syncope rule in a colombian population. Europace 17(SUPPL):iii198

    Google Scholar 

  23. Han H, Santos M (2010) Long-term outcomes of patients presenting with syncope to a major victorian Emergency Department. Heart Lung Circ 19(SUPPL):S221

    Article  Google Scholar 

  24. Kayayurt K, Akoglu H, Limon O et al (2012) Comparison of existing syncope rules and newly proposed anatolian syncope rule to predict short-term serious outcomes after syncope in the Turkish population. Int J Emerg Med 5:17. https://doi.org/10.1186/1865-1380-5-17

    Article  PubMed  PubMed Central  Google Scholar 

  25. Long BJ, Serrano LA, Chandra S et al (2011) Does mode of transportation to the Emergency Department predict subsequent cardiopulmonary adverse events in patients with syncope? Ann Emerg Med 58:S260

    Article  Google Scholar 

  26. Numeroso F, Mossini G, Giovanelli M et al (2016) Short-term prognosis and current management of syncopal patients at intermediate risk: results from the IRiS (Intermediate-Risk Syncope) study. AcadEmergMed 23:941–948

    Google Scholar 

  27. Numeroso F, Mossini G, Montali F et al (2013) Prognostic value of the OESIL risk score in a cohort of Emergency Department patients with syncope. Minerva Med 104:413–419

    PubMed  CAS  Google Scholar 

  28. Quinn J, McDermott D, Kramer N et al (2008) Death after Emergency Department visits for syncope: how common and can it be predicted? Ann Emerg Med 51:585–590

    Article  PubMed  Google Scholar 

  29. Racco F, Sconocchini C, Reginelli R et al (1993) Syncope in a general population: etiologic diagnosis and follow-up. Results of a prospective study. Minerva Med 84:249–261

    PubMed  CAS  Google Scholar 

  30. Reed MJ, Henderson SS, Newby DE, Gray AJ (2011) One-year prognosis after syncope and the failure of the ROSE decision instrument to predict one-year adverse events. Ann Emerg Med 58:250–256. https://doi.org/10.1016/j.annemergmed.2010.12.021

    Article  PubMed  Google Scholar 

  31. Reed MJ, Newby DE, Coull AJ et al (2007) Role of brain natriuretic peptide (BNP) in risk stratification of adult syncope. Emerg Med J 24:769–773

    Article  PubMed  PubMed Central  Google Scholar 

  32. Reed MJ, Newby DE, Coull AJ et al (2010) The ROSE (risk stratification of syncope in the Emergency Department) study. J Am Coll Cardiol 55:713–721

    Article  PubMed  CAS  Google Scholar 

  33. Safari S, Baratloo A, Hashemi B et al (2016) Comparison of different risk stratification systems in predicting short-term serious outcome of syncope patients. J Res Med Sci 21(1):57. https://doi.org/10.4103/1735-1995.187305

    Article  PubMed  PubMed Central  Google Scholar 

  34. Sruamsiri K, Chenthanakij B, Tantiwut A, Wittayachamnankul B (2014) Usefulness of syncope guidelines in risk stratification of syncope in Emergency Department. J Med Assoc Thail 97:173–178

    Google Scholar 

  35. Sun B, Derose S (2013) ECG predictors of 30-day cardiac events after syncope. Acad Emerg Med 20:S221

    Article  Google Scholar 

  36. Sun BC, McCreath H, Liang L-J et al (2014) Randomized clinical trial of an Emergency Department observation syncope protocol versus routine inpatient admission. Ann Emerg Med 64:167–175. https://doi.org/10.1016/j.annemergmed.2013.10.029

    Article  PubMed  Google Scholar 

  37. Tan C, Sim TB, Thng SY (2012) Validation of the San Francisco syncope rule in two local hospitals Emergency Departments. Acad Emerg Med 19:743

    Google Scholar 

  38. Thiruganasambandamoorthy V, Kwong K, Wells GA et al (2016) Development of the Canadian Syncope Risk Score to predict serious adverse events after Emergency Department assessment of syncope. Can Med Assoc J 188:E289–E298. https://doi.org/10.1503/cmaj.151469

    Article  Google Scholar 

  39. Ungar A, Del Rosso A, Giada F et al (2010) Early and late outcome of treated patients referred for syncope to Emergency Department: the EGSYS 2 follow-up study. Eur Heart J 31:2021–2026

    Article  PubMed  Google Scholar 

  40. Ungar A, Tesi F, Chisciotti VM et al (2016) Assessment of a structured management pathway for patients referred to the Emergency Department for syncope: results in a tertiary hospital. Europace 18:457–462. https://doi.org/10.1093/europace/euv106

    Article  PubMed  Google Scholar 

  41. Volz KA, Smulowitz P, Shapiro NI et al (2013) Are one-day admissions better than emergency department observation in syncope patients? Ann Emerg Med 62:S112

    Article  Google Scholar 

  42. Saccilotto RT, Nickel CH, Bucher HC et al (2011) San Francisco Syncope Rule to predict short-term serious outcomes: a systematic review. CMAJ 183:E1116–E1126

    Article  PubMed  PubMed Central  Google Scholar 

  43. Serrano LA, Hess EP, Bellolio MF et al (2010) Accuracy and quality of clinical decision rules for syncope in the Emergency Department: a systematic review and meta-analysis. Ann Emerg Med 56:362–373

    Article  PubMed  PubMed Central  Google Scholar 

  44. Solbiati M, Casazza G, Dipaola F et al (2015) Syncope recurrence and mortality: a systematic review. Europace 17:300–308. https://doi.org/10.1093/europace/euu327

    Article  PubMed  Google Scholar 

  45. Solbiati M, Casazza G, Dipaola F et al (2017) The diagnostic yield of implantable loop recorders in unexplained syncope: a systematic review and meta-analysis. Int J Cardiol 231:170–176. https://doi.org/10.1016/j.ijcard.2016.12.128

    Article  PubMed  Google Scholar 

  46. Costantino G, Casazza G, Reed M et al (2014) Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis. Am J Med 127:1126.e13–25. https://doi.org/10.1016/j.amjmed.2014.05.022

    Article  PubMed  Google Scholar 

  47. D’Ascenzo F, Biondi-Zoccai G, Reed MJ et al (2013) Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the Emergency Department with syncope: an international meta-analysis. Int J Cardiol 167:57–62. https://doi.org/10.1016/j.ijcard.2011.11.083

    Article  PubMed  Google Scholar 

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Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Dipartimento di Medicina Interna, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy

    Monica Solbiati & Giorgio Costantino

  2. Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy

    Monica Solbiati

  3. Università degli Studi di Milano, Milan, Italy

    Viviana Bozzano

  4. Department of Biomedical Sciences, Humanitas University-Humanitas Research Hospital, Rozzano, Italy

    Franca Barbic, Franca Dipaola & Raffaello Furlan

  5. Dipartimento di Scienze Biomediche e Cliniche “L. Sacco”, Università degli Studi di Milano, Milan, Italy

    Giovanni Casazza

  6. Department of Emergency Medicine, Stanford University, Stanford, CA, USA

    James V. Quinn

  7. Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK

    Matthew J. Reed

  8. Department of Cardiac Sciences, University of Calgary, Calgary, Canada

    Robert S. Sheldon

  9. Department of Cardiology, Mayo Clinic, Phoenix, AZ, USA

    Win-Kuang Shen

  10. Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA

    Benjamin C. Sun

  11. Department of Emergency Medicine, University of Ottawa, Ottawa, Canada

    Venkatesh Thiruganasambandamoorthy

Authors
  1. Monica Solbiati
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  2. Viviana Bozzano
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  3. Franca Barbic
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  4. Giovanni Casazza
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  5. Franca Dipaola
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  6. James V. Quinn
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  7. Matthew J. Reed
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  8. Robert S. Sheldon
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  9. Win-Kuang Shen
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  10. Benjamin C. Sun
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  11. Venkatesh Thiruganasambandamoorthy
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  12. Raffaello Furlan
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  13. Giorgio Costantino
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Contributions

GCo, MS, and VB conceptually developed and designed the review; VB searched for articles and co-ordinated the review; VB, MS, and GCo screened articles and performed data extraction; MS and GCa performed data analysis; all the authors interpreted the data, participated in the conference call, commented on, and approved the final version of the manuscript. All the authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Correspondence to Monica Solbiati.

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Solbiati, M., Bozzano, V., Barbic, F. et al. Outcomes in syncope research: a systematic review and critical appraisal. Intern Emerg Med 13, 593–601 (2018). https://doi.org/10.1007/s11739-018-1788-z

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