From the Guidelines
Hospital admission for syncope patients is recommended for those with serious medical conditions potentially relevant to the cause of syncope, as identified during initial evaluation. The criteria for hospital admission in patients presenting with syncope include the presence of serious underlying cardiac conditions such as arrhythmias, structural heart disease, or evidence of acute coronary syndrome 1. Admission is also warranted for those with abnormal ECG findings, significant comorbidities, or advanced age with high-risk features.
Key Admission Criteria
- Serious medical conditions potentially relevant to the cause of syncope
- Abnormal ECG findings, including QT prolongation, bundle branch blocks, or ST-segment changes
- Significant comorbidities
- Advanced age (typically over 60-65 years) with high-risk features
- Syncope associated with physical exertion, occurring in the supine position, or without prodromal symptoms
- Significant injuries resulting from the syncopal event
- Persistent vital sign abnormalities, such as hypotension or hypoxemia
- Concerning neurological findings
- History of heart failure, previous myocardial infarction, or unexplained recurrent syncope episodes
According to the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope, hospital evaluation and treatment are recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation 1. It is reasonable to manage patients with presumptive reflex-mediated syncope in the outpatient setting in the absence of serious medical conditions. However, possible exceptions that might require hospital-based evaluation include frequent recurrent syncope with risk of injury or identified injury related to syncope 1.
Outpatient Management
- Patients with presumptive reflex-mediated syncope without serious medical conditions can be managed in the outpatient setting
- Patients with clear vasovagal or orthostatic cause, normal ECG, and no concerning medical history can often be safely discharged with appropriate follow-up
- Expedited referral to specialists with expertise in syncope may be considered as an alternative to extended hospital-based evaluation 1
From the Research
Criteria for Hospital Admission
The criteria for hospital admission in a patient presenting with syncope include:
- High-risk patients with cardiovascular or structural heart disease 2
- History concerning for arrhythmia 2
- Abnormal electrocardiographic findings 2
- Severe comorbidities 2
- Medium to high risk according to the Canadian Syncope Risk Score (CSRS) 3
Evaluation and Risk Stratification
The initial assessment for all patients presenting with syncope includes:
- A detailed history 2
- Physical examination 2
- Electrocardiography 2
- Laboratory testing and neuroimaging if clinically indicated 2
- Several comparable clinical decision rules can be used to assess the short-term risk of death and the need for hospital admission 2
Benefits of Hospital Admission
Hospital admission is beneficial for detecting serious adverse events among emergency department patients with syncope, particularly those with medium to high risk according to the CSRS 3
- Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0,95% confidence interval [CI] 3.3-7.4) 3
- However, the benefit of hospital admission is low for patients at low risk of a serious adverse event 3
Specialized Approaches
Standardized approaches to the investigation of syncope, such as guidelines, pathways, and checklists, can improve health services delivery 4
- Emergency department decision rules, specialized syncope-monitoring units, and formal diagnostic algorithms have been developed to provide standardized approaches to the investigation of syncope 4
- The Canadian Cardiovascular Society position paper provides guidance on the management of syncope, including recommendations on standardized approaches to syncope investigation in adults 4