Canadian Syncope Risk Score Helpful for Triage in the Emergency Department

NEW YORK (Reuters Health) – The Canadian Syncope Risk Score (CSRS) can help identify patients at low risk for serious outcomes and, therefore, possible candidates for discharge from the emergency department (ED), an international validation study suggests.

However, the “incremental value and clinical utility of the CSRS remains unclear and warrants further study,” Dr. Christian Mueller of University Hospital Basel, in Switzerland, and colleagues write in Annals of Internal Medicine.

Most causes of syncope are benign, but those due to cardiac causes may be life-threatening and distinguishing patients at low versus high risk during the ED visit is challenging.

“In the absence of accurate risk stratification, this uncertainty leads to hospitalization in up to 80% of patients, with associated costs exceeding $2.4 billion in the United States annually,” they point out.

Researchers developed the CSRS to predict a composite of serious clinical plus procedural events at 30 days not evident during the ED assessment of syncope.

An initial study conducted in Canada showed “high prognostic accuracy” but two small validation studies found only “moderate” performance.

This led the team to externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score, in 2,283 ED patients (mean age, 68 years) with syncope from eight countries.

At 30 days, the primary composite outcome of serious clinical plus procedural events occurred in 7.2% of patients and the composite outcome excluding procedural interventions (secondary outcome) occurred in 3.1%.

Prognostic performance of the CSRS was good for both 30-day composite outcomes, and better than with the OESIL score (AUC 0.85 vs. 0.74 and AUC 0.80 vs. 0.69, respectively), the researchers report.

“By applying the CSRS, more than half of patients (60.8%) were triaged to the (very) low-risk group, in whom hospitalization often may not be necessary,” the study team reports. Fewer than 1% of patients identified as (very) low risk by the CSRS had adverse clinical outcomes at 30 days.

“Although, the CSRS did significantly better in predicting 30-day adverse outcomes not evident during index ED evaluation compared with the OESIL score, the performance of the CSRS was mainly driven by clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) at ED discharge,” they note.

“Given that a simplified model based only on this syncope classification variable achieved similar discrimination versus the CSRS, the incremental clinical value of the CSRS is likely marginal in EDs with a similar standard of care to the 14 EDs across eight countries contributing to this study,” they write.

Having an accurate way to identify low-risk syncope patients in the ED could have a high economic impact, they point out.

“Given the average cost of hospitalization for syncope of around $8700, an estimated 1.5 million patients presenting to the ED with syncope in the United States and Europe annually, reduction in the rate of hospitalization from 60% to 50% by the improved identification of patients at low risk could result in health care savings of more than $1.3 billion in the United States and Europe alone,” they calculate.

SOURCE: Annals of Internal Medicine, online April 25, 2022.

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