Clinical question:Among older adults, what risk factors predict adverse events following syncope?

Background: Older adults with syncope are hospitalized regularly, although little data exist to substantiate such practice. These hospitalizations consume significant health resources and could have low diagnostic and therapeutic yields. Risk-assessment tools might help EDs identify low-risk patients eligible for early discharge versus high-risk patients requiring further monitoring.

Study design: Retrospective study of administrative data.

Setting: Regional managed-care system.

Synopsis: This retrospective study of 2,584 patients (age ≥60 years) across three EDs identified risk factors for 30-day adverse events following near-syncope or syncope. Compared with prior studies, the study enrolled larger numbers of patients and was the first to specifically study older adults. Adverse events included arrhythmia, myocardial infarction (MI), stroke, and pulmonary embolism (PE).

Using multivariable logistic regression, the study identified six easily obtainable predictors of increased risk (age >90 years, male sex, arrhythmia, triage SBP>160 mm Hg, abnormal ECG, and abnormal troponin I) and one predictor of decreased risk (near-syncope). Using the seven predictors, a simple risk score for 30-day adverse events was created to stratify patients into low (2.5%), intermediate (6.3%), and high-risk (20%) groups.

Of note, the risk score categorized 31% of participants as low-risk, and the authors suggest that such patients might be eligible for brief observation or discharge from the ED. However, the authors also point out the score must be externally validated and prospectively evaluated, particularly in non-managed-care settings.

Bottom line: This risk score could be useful in stratifying the risk of serious post-syncopal events, but it needs to be externally validated before it can be adopted in clinical decision-making.

Reference: Sun BC, Derose SF, Liang LJ, et al. Predictors of 30-day serious events in older patients with syncope. Ann Emerg Med. 2009;54(6):769-778.e1-5.

Reviewed for TH Ewire by Glen Kim, MD, MPH, hospitalist, Brigham and Women’s Hospital and Harvard Medical School, Boston

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