Venkatesh Thiruganasambandamoorthy1,2,3, Marco L A Sivilotti4,5, Natalie Le Sage6,7, Justin W Yan8, Paul Huang9, Mona Hegdekar10, Eric Mercier6,7, Muhammad Mukarram2, Marie-Joe Nemnom2, Andrew D McRae11,12, Brian H Rowe13,14, Ian G Stiell1,2,3, George A Wells3, Andrew D Krahn15, Monica Taljaard2,3. 1. Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada. 2. Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada. 3. University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada. 4. Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada. 5. Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada. 6. Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada. 7. CHU de Québec - Université Laval Research Center, Quebec City, Quebec, Canada. 8. Division of Emergency Medicine, Western University, London, Ontario, Canada. 9. Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada. 10. Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. 11. Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada. 12. Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada. 13. Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada. 14. School of Public Health, University of Alberta, Edmonton, Alberta, Canada. 15. Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
Abstract
Importance: The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use. Objective: To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation. Design, Setting, and Participants: This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018. Main Outcomes and Measures: Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated. Results: A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively. Conclusions and Relevance: The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
Importance: The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use. Objective: To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation. Design, Setting, and Participants: This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018. Main Outcomes and Measures: Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated. Results: A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively. Conclusions and Relevance: The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
Authors: Erik von Elm; Douglas G Altman; Matthias Egger; Stuart J Pocock; Peter C Gøtzsche; Jan P Vandenbroucke Journal: Lancet Date: 2007-10-20 Impact factor: 79.321
Authors: Cristian Toarta; Muhammad Mukarram; Kirtana Arcot; Soo-Min Kim; Sarah Gaudet; Marco L A Sivilotti; Brian H Rowe; Venkatesh Thiruganasambandamoorthy Journal: Acad Emerg Med Date: 2018-01-11 Impact factor: 3.451
Authors: Jeanne du Fay de Lavallaz; Patrick Badertscher; Thomas Nestelberger; Tobias Zimmermann; Òscar Miró; Emilio Salgado; Michael Christ; Nicolas Geigy; Louise Cullen; Martin Than; F Javier Martin-Sanchez; Salvatore Di Somma; W Frank Peacock; Beata Morawiec; Joan Walter; Raphael Twerenbold; Christian Puelacher; Desiree Wussler; Jasper Boeddinghaus; Luca Koechlin; Ivo Strebel; Dagmar I Keller; Jens Lohrmann; Eleni Michou; Michael Kühne; Tobias Reichlin; Christian Mueller Journal: Circulation Date: 2019-02-25 Impact factor: 29.690
Authors: Venkatesh Thiruganasambandamoorthy; Kenneth Kwong; George A Wells; Marco L A Sivilotti; Muhammad Mukarram; Brian H Rowe; Eddy Lang; Jeffrey J Perry; Robert Sheldon; Ian G Stiell; Monica Taljaard Journal: CMAJ Date: 2016-07-04 Impact factor: 8.262
Authors: Jeanne du Fay de Lavallaz; Patrick Badertscher; Thomas Nestelberger; Rahel Isenrich; Òscar Miró; Emilio Salgado; Nicolas Geigy; Michael Christ; Louise Cullen; Martin Than; F Javier Martin-Sanchez; José Bustamante Mandrión; Salvatore Di Somma; W Frank Peacock; Damian Kawecki; Jasper Boeddinghaus; Raphael Twerenbold; Christian Puelacher; Desiree Wussler; Ivo Strebel; Dagmar I Keller; Imke Poepping; Michael Kühne; Christian Mueller; Tobias Reichlin; Maria Rubini Giménez; Joan Walter; Nikola Kozhuharov; Samyut Shrestha; Deborah Mueller; Lorraine Sazgary; Beata Morawiec; Piotr Muzyk; Ewa Nowalany-Kozielska; Michael Freese; Claudia Stelzig; Kathrin Meissner; Caroline Kulangara; Beate Hartmann; Ina Ferel; Zaid Sabti; Jaimi Greenslade; Tracey Hawkins; Katharina Rentsch; Arnold von Eckardstein; Andreas Buser; Wanda Kloos; Jens Lohrmann; Stefan Osswald Journal: Int J Cardiol Date: 2018-06-21 Impact factor: 4.164
Authors: Bassant Sayed Moussa; Mohamed Amin Ali; Ahmed Abd El-Nasser Ali; Ahmed El Sayed Mohammed Abou Zeid Journal: Medicine (Baltimore) Date: 2022-06-24 Impact factor: 1.817
Authors: Marc A Probst; Alexander T Janke; Adrian D Haimovich; Arjun K Venkatesh; Michelle P Lin; Keith E Kocher; Marie-Joe Nemnom; Venkatesh Thiruganasambandamoorthy Journal: Ann Emerg Med Date: 2022-04-27 Impact factor: 6.762