1. Background
•Syncope is usually a benign
symptom .
•It is associated occasionally
with significant morbidity and
mortality.
•As a result, syncope is often
referred to a “low-risk / high-
stakes” symptom.
•Many physicians admit these
patients even though they
believe are low risk because of
the high stakes involved.
To prospectively validate in the
ED, San Francisco Syncope
Rule. (history of congestive heart
failure, Hematocrit 30%,
abnormal ECG result [new
changes or non–sinus rhythm],
complaint of shortness of breath,
and systolic blood pressure 90
mm Hg during triage).
Aims & Objectives
•During study period, 371
patients visited ED with Syncope.
•The average age in study was
44 years with 77% predominantly
being male patients.
•Overall admission rate was
100%.
•In our study, 13.7% of patients
had definite serious outcomes
(108) within 30 days.
•Fifty Four patients had serious
outcomes during ED visit, and
remaining 54 patients had
serious outcome within next 30
days.
•Youngest patient was 10 years &
oldest was 88 years old.
•Commonest presentation during
ED visit was syncope followed by
neurological deficits and then
Chest pain.
•One Eighty Four were
hypertensive and 147 Diabetic.
•Haematocrit changes alone did
not make a significant difference
as only 24 patients required
blood transfusion.
Methods
Conclusion
The San Francisco Syncope
Rule performed with high
sensitivity and specificity in this
validation cohort and is valuable
tool to help risk stratify patients.
It may help with physician
decision making and improve
use of hospital admission for
syncope.
VALIDATION OF THE SAN FRANCISCO SYNCOPE RULE
TO PREDICT PATIENTS WITH SERIOUS OUTCOMES
IN EMERGENCY DEPARTMENT
Dr. Nishanth Hiremath.S*; Dr. Srihari Cattamanchi; Dr. T.V. Ramakrishnan;
Dr. Srinivas Reddy Banala; Dr. John Nobel Thomas.
Sri Ramchandra Medical College & Research Institute, Porur, Chennai – 600116. Tamil Nadu. India.
Results
Dr. Nishanth Hiremath,
Address: ; Mobile: ; Email id:;
Design: A Prospective, analytical
study.
Setting: Accident & Emergency
Department, of Sri Ramachandra
Medical College & Research
Institute, a tertiary care, level I
trauma centre in Chennai, India.
Duration: 1st January 2008 to
31st December 2009.
Instrument: A preformatted
questionnaire used to collect
demographic data, history of
congestive heart failure,
Haematocrit <30%, abnormal
ECG result, shortness of breath,
and a triage systolic blood
pressure <90 mm Hg.
Statistical Analysis: The
sensitivity and specificity, with
95% confidence intervals (CIs),
were calculated using SPSS
software Ver. 17.0.
Methodology: ER Physicians
prospectively applied San
Francisco Syncope Rule after
their initial evaluation, and
patients were followed up to
determine whether they had
predefined serious outcome
within 30 days of their ED visit
Inclusion criteria: Patients
presenting with or near
syncope for their ED visit were
considered for the study.
Patients with altered
consciousness or persistent
new neurologic deficits were
included.
Exclusion criteria: Loss of
consciousness due to trauma,
alcohol or drug abuse as well
as patients with a definite
seizure were excluded.
•Presenting ECG changes were
seen in 209 patients (56%).
•Out of 26 patients on whom
Holter was done 18 were positive
and had significant p value 0.000
•All patients underwent Echo in
which 247 had an abnormal
echo.
•MRI brain was significant during
the time of admission or within 30
days, as 71 patients had
significant finding.
•Sixty Six Percent of patients
were admitted in ICU.
•In period of 30 days, 259
patients were discharged, 40
patients were further investigated
and 40 patients died in hospital.
•Eight patients were discharged
against medical advice (DAMA).
•Among 259 patients discharged
from hospital only 140 patients
came for follow up.
•Remaining 119 were not
traceable.
•High risk patients were about
179 patients (48%).
Risk Score Sensitivity Specificity Positive
Predictive
Value
Negative
Predictive
Vale
Hematocrit 100 53.4 6.7 100
ECG
Changes
98.1 90.4 88.8 98.4
CHF 100 53.3 6.14 100
SOB 100 63.1 37.4 100
•The Sanfrancisco syncope rule
as a group had a highly
significant p value (<.0001) but
individually when the criteria was
taken it is not statistically
significant