Predictors of Short-Term Outcomes after Syncope: A Systematic Review and Meta-Analysis

Establishment and validation of a nomogram for predicting the risk of syncope after craniomaxillofacial surgery

PURPOSE

To explore the influencing factors of syncope in patients after plastic surgery, establish a syncope risk prediction model, and verify its accuracy.

METHODS

A total of 265 patients undergoing craniomaxillofacial surgery were included and divided into a syncope group and non-syncope group. Multivariate logistic regression analysis was used to screen for risk factors of syncope, and R language was used to establish a risk prediction nomogram of syncope in craniomaxillofacial surgery patients. The Hosmer-Lemeshow goodness-of-fit test was used to evaluate the fit of the model, and the receiver operating characteristic (ROC) curve was used to analyze the predictive value of the model.

RESULTS

Syncope occurred in 87 of 265 patients (32.8%), and no syncope occurred in 178 patients (67.8%). Multivariate logistic regression analysis revealed statistical differences in age, orthostatic heart rate, orthostatic diastolic blood pressure, syncope history, weight loss history, and medication history between the 2 groups (P < 0.05). A nomogram was constructed for predicting the risk of syncope after craniomaxillofacial surgery, and the Hosmer-Lemeshow goodness-of-fit test proved that the nomogram fitted well (P = 0.431). The results of ROC curve analysis showed that the alignment graph model had high prediction accuracy; the area under the curve was 0.886 (95% confidence interval, 0.8381-0.9332).

CONCLUSION

Evaluating the risk of syncope after craniomaxillofacial surgery is helpful and provides guidance for the formulation of preventive strategies.

Diagnostic accuracy of high sensitivity troponin and association of electrocardiogram findings for mortality in syncope patients: A retrospective cohort study

High-sensitivity cardiac troponin-T (hs-cTnT) and electrocardiogram (ECG) are commonly ordered in daily practice in emergency medicine but their value on long term mortality in syncope patients is unclear. Our aim is to determine the diagnostic accuracy of hs-cTnT and association of ECG findings for 1-year mortality in patients presenting with syncope. In this retrospective cohort study, we included patients presenting with syncope to the emergency department (ED) between May 2020 and May 2021. Patient demographics, vital parameters on admission, ECG findings, hs-cTnT level at admission and 1-year mortality status were recorded. The study included 417 patients (62.4% women) with a mean age of 41.51 (standard deviation [SD] 17.1), 21 of whom were deceased within 1 year after syncope attack (5%). Patients with an abnormal QTc, T-Axis or frontal QRS-T angle had significantly higher 1-year mortality (OR: 9.26, 95% CI: 1.64-52.31; OR: 5.82, 95% CI: 1.69-20.1; 4.94, 95% CI: 1.45-16.84, respectively). The hs-cTnT level was 21.92 pg/mL (95% CI: 3.35-40.51 pg/mL) higher in the mortality group (P = .023). An abnormal QTc, T-Axis and frontal QRS-T angle are associated with a higher 1-year mortality rate and hs-cTnT has good diagnostic accuracy in detecting 1-year mortality for patients presenting with syncope.

e Silva L. Prognostic accuracy of syncope clinical prediction rules in older adults in the emergency department

Study objective

The objective of this study is to evaluate the prognostic accuracy of existing rules (San Francisco Syncope Rule [SFSR], Canadian Syncope Risk Score [CSRS], and FAINT score) in older adults.

Methods

This is a cohort study of adults aged ≥60 years presenting to an academic emergency department (ED) with syncope or near syncope. We used original criteria for all rules except for the FAINT score, in which N-terminal pro-brain natriuretic peptide was largely missing from the extracted data. Patients were deemed positive for each rule if classified as non-low risk. The primary outcome was the presence of 30-day serious outcome, as defined by syncope research guidelines. Sensitivity and negative likelihood ratio (NLR) were calculated with 95% confidence intervals (CIs).

Results

A total of 404 ED visits (mean age of patients, 75.5 years) were included. Of these, 44 (10.9%) had a 30-day serious outcome, and 24 (5.9%) had incomplete 30-day follow-up. SFSR was positive for 280 of 380 visits with complete follow-up. Its sensitivity and NLR for predicting 30-day serious outcomes were 86.4% (95% CI, 72.0%-94.3%) and 0.53 (95% CI, 0.25-1.15), respectively. The CSRS was positive for 299 of 380 visits (sensitivity was 88.6% [95% CI, 76.4%-95.7%], and NLR was 0.50 [95% CI, 0.22-1.17]). The modified FAI(N)T score was positive for 318 of 380 visits (sensitivity was 90.9% [95% CI, 77.4%-97.0%], and NLR was 0.53 [95% CI, 0.20-1.38]).

Conclusion

Existing rules are suboptimal to predict 30-day serious outcomes in older adults presenting with syncope or near syncope to the ED.

Diagnostic value of cardiac troponin I and N-terminal pro-B-Type Natriuretic Peptide in cardiac syncope

Objective

The study aims to evaluate the diagnostic accuracy of Cardiac Troponin I(cTnI) and N-terminal pro-B-Type Natriuretic Peptide (NT-proBNP) for identifying patients with cardiac syncope.

Methods

This is a prospective, single-center cohort study of patients presenting with syncope hospitalized from June 21,2018 to May 30, 2019. The Evaluation of Guidelines in Syncope Study (EGSYS), a syncope-specific diagnostic score, was used for diagnostic comparator.

Results

A total of 118 patients were enrolled (mean age: 69.1 ​± ​12.3 years, 40% female). Compared to patients with reflex, orthostatic, or unexplained syncope, patients adjudicated to have cardiac syncope showed significantly higher cTnI and NT-proBNP plasma concentrations (p ​< ​0.001 for each comparison). The area under the curve (AUC) of cTnI and NT-proBNP were moderate-to-good [0.77–0.78; 95% confidence interval (CI) 0.66–0.86], and was similar to that of EGSYS (0.71, 95%CI 0.60–0.80). Incorporation of cTnI and/or NT-proBNP into the existing EGSYS score significantly improved the diagnostic accuracy (EGSYS ​+ ​cTnI: AUC 0.83; 95%CI 0.74–0.90; EGSYS ​+ ​NT-proBNP: AUC 0.81; 95%CI 0.71–0.89; EGSYS ​+ ​cTnI ​+ ​NT-proBNP: AUC 0.83; 95%CI 0.73–0.90).

Conclusions

The cTnI and NT-proBNP levels were significantly higher in patients adjudicated to have cardiac syncope and the addition of both biomarkers to the EGSYS score significantly improved the diagnostic value for cardiac syncope.

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CTnI and NT-proBNP levels were significantly higher in patients adjudicated to have cardiac syncope.

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Firstly incorporation of cTnI and NT-proBNP to the EGSYS score, which significantly improved the diagnosis value.

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Incorporation of both biomarkers to the EGSYS score significantly improved its predictive performance.

Multivariable risk scores for predicting short-term outcomes for emergency department patients with unexplained syncope: A systematic review

OBJECTIVES

Emergency department (ED) patients with unexplained syncope are at risk of experiencing an adverse event within 30 days. Our objective was to systematically review the accuracy of multivariate risk stratification scores for identifying adult syncope patients at high and low risk of an adverse event over the next 30 days.

METHODS

We conducted a systematic review of electronic databases (MEDLINE, Cochrane, Embase, and CINAHL) from database creation until May 2020. We sought studies evaluating prediction scores of adults presenting to an ED with syncope. We included studies that followed patients for up to 30 days to identify adverse events such as death, myocardial infarction, stroke, or cardiac surgery. We only included studies with a blinded comparison between baseline clinical features and adverse events. We calculated likelihood ratios and confidence intervals (CIs).

RESULTS

We screened 13,788 abstracts. We included 17 studies evaluating nine risk stratification scores on 24,234 patient visits, where 7.5% (95% CI = 5.3% to 10%) experienced an adverse event. A Canadian Syncope Risk Score (CSRS) of 4 or more was associated with a high likelihood of an adverse event (LR_score≥4  = 11, 95% CI = 8.9 to 14). A CSRS of 0 or less (LR_score≤0  = 0.10, 95% CI = 0.07 to 0.20) was associated with a low likelihood of an adverse event. Other risk scores were not validated on an independent sample, had low positive likelihood ratios for identifying patients at high risk, or had high negative likelihood ratios for identifying patients at low risk.

CONCLUSION

Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known.

[Diagnostic value of high-sensitivity troponin I to predict cardiac causes after syncope/near syncope in emergency department]

AIMS

The objective of this study is to evaluate the diagnostic accuracy of high-sensitivity (hs) troponin I to predict cardiac origin after syncope. The secondary objective is to determine the causes of elevated troponin.

PROCEDURE

Were included hospitalized patients with syncope/near syncope diagnosed in ED. The diagnostic accuracy to predict cardiac origin was evaluated and compared to the "high risk" group, defined by the 2018 European Society of Cardiology guidelines.

RESULTS

A total of 163 patients were enrolled, 26% had a cardiac origin. Positive troponin I hs predict a cardiac origin with a sensitivity of 31%, a specificity of 80%, positive predictive value of 35% and negative value of 77%. These diagnostic performances are not discriminating and lower than the ESC classification. A positive troponine I hs level is associated with 5 times more cardiac failure during the hospitalization.

CONCLUSION

A positive troponin I hs level after syncope/near syncope is not predictive of cardiac origin. It appears to be an early marker of ventricular remodeling in heart failure.

Prognosis of Syncope With Head Injury: a Tertiary Center Perspective

Aim: Head injury is the most common trauma occurring in syncope. We aimed to assess whether syncope as cause of head-trauma affects short-and long-term prognosis.

Methods: From a database retrospective analysis of 97,014 individuals attending Emergency Department (ED), we selected data of patients with traumatic head injury including age, gender, injury mechanism, brain imaging, multiple traumas, bone fracture, intracranial bleeding, and mortality. Mean follow-up was 6.4 ± 1.8 years. Outcome data were obtained from a digital national population register. The study population included 3,470 ED head injury patients: 117 of them (50.0 ± 23.6 years, 42.7% men) reported syncope as cause of head trauma and 3,315 (32.2 ± 21.1 years, 68.5% men) without syncope preceding head trauma.

Results: Thirty-day mortality was low and similar in traumatic head injury with or without syncope. One year and long-term all-cause mortality were both significantly higher in syncopal vs. non-syncopal traumatic head injury (11.1 vs. 2.8% and 32 vs. 10.2%, respectively; both p < 0.001). In adjusted logistic regression analysis, death between 121st-day and 1 year in patients with head-trauma was associated with male gender [odds ratio (OR): 6.48; 95% CI: 2.59–16.25], advancing age (per year) (OR 1.09; 95% CI 1.07–1.11), Glasgow Coma Scale < 13 (OR: 6.18; 95% CI:1.68–22.8), bone fracture (OR 4.72; 95% CI 2.13–10.5), and syncope (OR 3.70; 95% CI: 1;48–9.31). In multivariable Cox regression analysis, syncope was one of the strongest independent predictors of long-term all-cause death (hazard ratio: 1.95; 95% CI 1.37–2.78).

Conclusion: In patients with head trauma, history of syncope preceding injury does not increase 30-day all-cause mortality but portends increased 1 year and long-term mortality.

Role of Biomarkers in the Prediction of Serious Adverse Events after Syncope in Prehospital Assessment: A Multi-Center Observational Study

Syncope is defined as the nontraumatic, transient loss of awareness of rapid onset, short duration and with complete spontaneous recovery, and accounts for 1%–3% of all visits to the emergency department. The objective of this study was to evaluate the predictive capacity of the National Early Warning Score 2 (NEWS2) and prehospital lactate (pLA), individually and combined, at the prehospital level to detect patients with syncope at risk of early mortality (within 48 h) in the hospital environment. A prospective, multicenter cohort study without intervention was carried out on syncope patients aged over 18 who were given advanced life support and taken to the hospital. Our study included a total of 361 cases. Early mortality affected 21 patients (5.8%). The combined score formed by the NEWS2 and the pLA (NEWS2-L) obtained an AUC of 0.948 (95% CI: 0.88–1) and an odds ratio of 86.25 (95% CI: 11.36–645.57), which is significantly higher than that obtained by the NEWS2 or pLA in isolation (p = 0.018). The NEWS2-L can help stratify the risk in patients with syncope treated in the prehospital setting, with only the standard measurement of physiological parameters and pLA.

Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study

BACKGROUND

Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope.

METHODS

We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs.

RESULTS

The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18).

CONCLUSIONS

In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes.

Risk Stratification of Older Adults Who Present to the Emergency Department With Syncope: The FAINT Score

STUDY OBJECTIVE

Older adults with syncope are commonly treated in the emergency department (ED). We seek to derive a novel risk-stratification tool to predict 30-day serious cardiac outcomes.

METHODS

We performed a prospective, observational study of older adults (≥60 years) with unexplained syncope or near syncope who presented to 11 EDs in the United States. Patients with a serious diagnosis identified in the ED were excluded. We collected clinical and laboratory data on all patients. Our primary outcome was 30-day all-cause mortality or serious cardiac outcome.

RESULTS

We enrolled 3,177 older adults with unexplained syncope or near syncope between April 2013 and September 2016. Mean age was 73 years (SD 9.0 years). The incidence of the primary outcome was 5.7% (95% confidence interval [CI] 4.9% to 6.5%). Using Bayesian logistic regression, we derived the FAINT score: history of heart failure, history of cardiac arrhythmia, initial abnormal ECG result, elevated pro B-type natriuretic peptide, and elevated high-sensitivity troponin T. A FAINT score of 0 versus greater than or equal to 1 had sensitivity of 96.7% (95% CI 92.9% to 98.8%) and specificity 22.2% (95% CI 20.7% to 23.8%), respectively. The FAINT score tended to be more accurate than unstructured physician judgment: area under the curve 0.704 (95% CI 0.669 to 0.739) versus 0.630 (95% CI 0.589 to 0.670).

CONCLUSION

Among older adults with syncope or near syncope of potential cardiac cause, a FAINT score of zero had a reasonably high sensitivity for excluding death and serious cardiac outcomes at 30 days. If externally validated, this tool could improve resource use for this common condition.

Predicting mortality with cardiac troponins: recent insights from meta-analyses

The introduction of cardiac troponin (cTn) testing in clinical practice has been one of the most important breakthroughs that have occurred in the recent history of laboratory medicine. Although it is now uncontestable that cTn values are essential for diagnosing acute coronary syndrome (ACS), solid evidence is also emerging that assessment of either cardiac troponin I (cTnI) or T (cTnT) may provide valuable prognostic information in the general healthy population, as well as in patients with a vast array of cardiac and extra-cardiac diseases. We have hence performed a critical review of the scientific literature for identifying meta-analyses which have investigated the potential contribution of cTns in predicting the risk of death in health and disease. According to the articles identified with our research, we can conclude that increased cTn values may be considered independent risk factors for all-cause mortality in the general population, as well as in patients with ACS, in those undergoing revascularization procedures, or with stable coronary artery disease (CAD), heart failure (HF) and atrial fibrillation (AF). Measurement of cTn may then be helpful for stratifying the mortality risk in non-cardiac hospitalized patients, in those with critical illness or sepsis, syncope, stroke, acute aortic dissection, pulmonary diseases, brain injury, renal failure, vascular and non-cardiac surgery. Although this evidence has notable clinical implications, the cost-effectiveness of population screening with high-sensitivity (hs) cTn immunoassays has not been proven so far.

Do High-sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope?

OBJECTIVES

An estimated 1.2 million annual emergency department (ED) visits for syncope/near syncope occur in the United States. Cardiac biomarkers are frequently obtained during the ED evaluation, but the prognostic value of index high-sensitivity troponin (hscTnT) and natriuretic peptide (NT-proBNP) are unclear. The objective of this study was to determine if hscTnT and NT-proBNP drawn in the ED are independently associated with 30-day death/serious cardiac outcomes in adult patients presenting with syncope.

METHODS

A prespecified secondary analysis of a prospective, observational trial enrolling participants ≥ age 60 presenting with syncope, at 11 United States hospitals, was conducted between April 2013 and September 2016. Exclusions included seizure, stroke, transient ischemic attack, trauma, intoxication, hypoglycemia, persistent confusion, mechanical/electrical invention, prior enrollment, or predicted poor follow-up. Within 3 hours of consent, hscTnT and NT-proBNP were collected and later analyzed centrally using Roche Elecsys Gen 5 STAT and 2010 Cobas, respectively. Primary outcome was combined 30-day all-cause mortality and serious cardiac events. Adjusting for illness severity, using multivariate logistic regression analysis, variations between primary outcome and biomarkers were estimated, adjusting absolute risk associated with ranges of biomarkers using Bayesian Markov Chain Monte Carlo methods.

RESULTS

The cohort included 3,392 patients; 367 (10.8%) experienced the primary outcome. Adjusted absolute risk for the primary outcome increased with hscTnT and NT-proBNP levels. HscTnT levels ≤ 5 ng/L were associated with a 4% (95% confidence interval [CI] = 3%-5%) outcome risk, and hscTnT > 50 ng/L, a 29% (95% CI = 26%-33%) risk. NT-proBNP levels ≤ 125 ng/L were associated with a 4% (95% CI = 4%-5%) risk, and NT-proBNP > 2,000 ng/L a 29% (95% CI = 25%-32%) risk. Likelihood ratios and predictive values demonstrated similar results. Sensitivity analyses excluding ED index serious outcomes demonstrated similar findings.

CONCLUSIONS

hscTnT and NT-proBNP are independent predictors of 30-day death and serious outcomes in older ED patients presenting with syncope.

Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope

STUDY OBJECTIVE

Controversy remains in regard to the risk of adverse events for patients presenting with syncope compared with near-syncope. The purpose of our study is to describe the difference in outcomes between these groups in a large multicenter cohort of older emergency department (ED) patients.

METHODS

From April 28, 2013, to September 21, 2016, we conducted a prospective, observational study across 11 EDs in adults (≥60 years) with syncope or near-syncope. A standardized data extraction tool was used to collect information during their index visit and at 30-day follow-up. Our primary outcome was the incidence of 30-day death or serious clinical events. Data were analyzed with descriptive statistics and multivariate logistic regression analysis adjusting for relevant demographic or historical variables.

RESULTS

A total of 3,581 patients (mean age 72.8 years; 51.6% men) were enrolled in the study. There were 1,380 patients (39%) presenting with near-syncope and 2,201 (61%) presenting with syncope. Baseline characteristics revealed a greater incidence of congestive heart failure, coronary artery disease, previous arrhythmia, nonwhite race, and presenting dyspnea in the near-syncope compared with syncope cohort. There were no differences in the primary outcome between the groups (near-syncope 18.7% versus syncope 18.2%). A multivariate logistic regression analysis identified no difference in 30-day serious outcomes for patients with near-syncope (odds ratio 0.94; 95% confidence interval 0.78 to 1.14) compared with syncope.

CONCLUSION

Near-syncope confers risk to patients similar to that of syncope for the composite outcome of 30-day death or serious clinical event.