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Circulation. 2017;136:e60–e122. DOI: 10.1161/CIR.0000000000000499 August 1, 2017 e73 CLINICAL STATEMENTS AND GUIDELINES

Table 6.  Examples of Syncope Risk Scores

Study/ Reference Year Sample N Events

N (%) Outcome Definition ED Events* Predictors NPV (%)†

Martin90 1997 252 104 (41%) 1-y death/arrhythmia Yes Abnormal ECG‡; >45 y of age; VA; HF 93 Sarasin74 2003 175 30 (17%) Inpatient arrhythmia Yes Abnormal ECG‡; >65 y of age; HF 98 OESIL67 2003 270 31 (11%) 1-y death N/A Abnormal ECG‡; >65 y of age; no prodrome; cardiac history 100 SFSR72 2004 684 79 (12%) 7-d serious events§ Yes Abnormal ECG‡; dyspnea; hematocrit; systolic BP <90 mm Hg; HF

99 Boston Syncope Rule70

2007 293 68 (23%) 30-d serious events‖ Yes Symptoms of acute coronary syndrome; worrisome cardiac history; family history of SCD; VHD; signs of conduction disease; volume depletion; persistent abnormal vital signs; primary central nervous event 100

Del Rosso69 2008 260 44 (17%) Cardiac etiology N/A Abnormal ECG‡/cardiac history; palpitations; exertional; supine; precipitant (a low-risk factor); autonomic prodrome (low-risk factors)

99 STePS68 2008 676 41 (6%) 10-d serious events¶ Yes Abnormal ECG‡; trauma; no prodrome; male sex

–

Syncope Risk Score75 2009 2584 173 (7%) 30-d serious events# No Abnormal ECG‡; >90 y of age; male sex; positive troponin; history of arrhythmia; systolic BP >160 mm Hg; near-syncope (a lowrisk factor) 97 ROSE73 2010 550 40 (7%) 30-d serious events# Yes Abnormal ECG‡; B-natriuretic peptide; hemoglobin; O2Sat; fecal occult blood 98 *Did the study include events diagnosed during the ED evaluation? †NPV: negative predictive value for lowest-risk group for the specific events defined by the study. ‡Abnormal ECG is defined variably in these studies. In the context of syncope evaluation, an abnormal ECG is any rhythm other than normal sinus rhythm, conduction delays (BBB, type-2 second-degree AVB or third-degree AVB), presence of Q waves, ST abnormalities, or prolonged QT interval. §Events: death, MI, arrhythmia, pulmonary embolism, stroke, hemorrhage, or readmission. ║Events: death, major therapeutic procedure, MI, arrhythmia, pulmonary embolism, stroke, sepsis, hemorrhage, or life-threatening sequelae of syncope. ¶Events: death, major therapeutic procedure, or readmission. #Events: death, arrhythmia, MI, new diagnosis of severe structural heart disease, pulmonary embolism, aortic dissection, stroke/TIA, cerebral hemorrhage, or significant anemia requiring blood transfusion. AVB indicates atrioventricular block; BBB, bundle-branch block; BP, blood pressure; ECG, electrocardiogram; ED, emergency department; HF, heart failure; MI, myocardial infarction; N/A, not available; NPV, negative predictive value; O2Sat, oxygen saturation; OESIL, Osservatorio Epidemiologico sulla Sincope nel Lazio; ROSE, Risk Stratification of Syncope in the ED; SCD, sudden cardiac death; SFSR, San Francisco Syncope Rule; STePS, Short-Term Prognosis of Syncope Study; TIA, transient ischemic attack; VA, ventricular arrhythmias; and VHD, valvular heart disease.

Recommendation for In-Hospital Telemetry

COR LOE Recommendation

I B-NR Continuous ECG monitoring is useful for hospitalized patients admitted for syncope evaluation with suspected cardiac etiology.77,182,183

See Online Data Supplement 13. Given that patients with syncope and structural heart disease are at high risk of death or significant arrhythmia,184 inpatient telemetry could be a valuable diagnostic modality. However, the diagnostic yield of inpatient telemetry is low in the absence of high suspicion about an arrhythmic cause.183 One study of 172 patients with syncope presenting to the ED and admitted to a telemetry unit revealed a diagnostic yield in 18% of patients, with 15% demonstrating bradyarrhythmias.182 The yield was highest in older patients with HF. No deaths occurred within an average monitoring time of 4.8±2.7 days. In 1 prospective study of 2240 patients admitted to a telemetry unit, patients admitted for syncope (10%) had low rates of unexpected intensive care transfer, and most were unrelated to arrhythmic conditions.185 Furthermore, in another prospective evaluation of 205 patients admitted to telemetry, significant arrhythmias were seen in only 12 patients with known or suspected coronary artery disease or in those with previously documented arrhythmias.183 No arrhythmias or interventions occurred in the 7% of patients who were assigned to telemetry because of syncope. A large, prospective evaluation of 2106 patients admitted with syncope demonstrated high telemetry use (95%) but a diagnostic yield of only 5%.77 Continuous telemetry in the hospital for patients presenting with syncope not suspected of a cardiac etiology is not cost-effective.186,187

3.2.4 In-Hospital Telemetry: Recommendation

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