What is the syncope (fainting) scoring system?

From the Guidelines

The most widely used syncope scoring system is the San Francisco Syncope Rule (SFSR), which helps determine the risk of serious outcomes in patients presenting with syncope. The SFSR uses the acronym CHESS to assess five key factors: C - Congestive heart failure history, H - Hematocrit < 30%, E - ECG abnormal, S - Shortness of breath, and S - Systolic blood pressure < 90 mmHg at triage. If any of these factors are present, the patient is considered high-risk and should be admitted for further evaluation. If none are present, the patient may be safely discharged with outpatient follow-up. This scoring system is valuable because it helps clinicians quickly identify patients at higher risk for adverse outcomes, allowing for more efficient and appropriate management of syncope cases, as supported by the guidelines from the American College of Cardiology, American Heart Association, and Heart Rhythm Society 1.

Key Factors in the SFSR

• Congestive heart failure history
• Hematocrit < 30%
• ECG abnormal
• Shortness of breath
• Systolic blood pressure < 90 mmHg at triage

Using the SFSR

1. Assess each patient for the CHESS criteria
2. Document the presence or absence of each factor
3. Determine risk based on the presence of any factor
4. Make admission or discharge decisions accordingly

Importance of Clinical Judgment

While the SFSR is widely used, it's essential to note that clinical judgment should always be exercised alongside any scoring system, as individual patient factors may necessitate deviation from the rule in some cases, as highlighted in the guidelines 1. The SFSR is particularly useful in emergency department settings where rapid decision-making is crucial, and its application can be supported by the evidence from the European Heart Journal 1.

From the Research

Syncope Scoring Systems

The syncope scoring system is used to predict short-term serious outcomes in patients presenting with syncope. Some of the commonly used scoring systems include:

• San Francisco Syncope Rule: This rule includes five predictor variables: abnormal ECG result, shortness of breath, hematocrit level less than 30%, triage systolic blood pressure less than 90 mm Hg, and history of congestive heart failure 2, 3, 4.
• Evaluation of Guidelines in Syncope Study (EGSYS) risk score: This score is used to predict short-term serious outcomes in patients with syncope, but its components are not specified in the provided studies.
• Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score: This score is also used to predict short-term serious outcomes in patients with syncope, but its components are not specified in the provided studies.
• Anatolian Syncope Rule (ASR): This rule includes six predictor variables: dyspnoea, orthostatic hypotension, precipitating cause of syncope, age over 58 years, congestive heart failure, and electrocardiogram abnormality (termed DO-PACE) 5.

Components of Syncope Scoring Systems

The components of the syncope scoring systems vary, but some common variables include:

• Abnormal ECG result
• Shortness of breath
• Hematocrit level less than 30%
• Triage systolic blood pressure less than 90 mm Hg
• History of congestive heart failure
• Dyspnoea
• Orthostatic hypotension
• Precipitating cause of syncope
• Age over 58 years
• Electrocardiogram abnormality

Performance of Syncope Scoring Systems

The performance of the syncope scoring systems varies, with sensitivity and specificity ranging from 56% to 100% 2, 3, 5, 4. The San Francisco Syncope Rule has been shown to have high sensitivity and specificity in predicting short-term serious outcomes, but its performance may vary depending on the population and setting 2, 3, 4. The Anatolian Syncope Rule has been shown to have high sensitivity and specificity in predicting short-term serious outcomes in the Turkish population 5.