Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.
JAMA Intern Med. 2020 May 1;180(5):737-744. doi: 10.1001/jamainternmed.2020.0288.
The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use.
To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation.
DESIGN, SETTING, AND PARTICIPANTS: This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018.
Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated.
A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively.
The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
由于没有推荐用于临床使用的稳健风险工具，急诊科（ED）中晕厥患者的管理具有挑战性。
在新的晕厥患者队列中验证加拿大晕厥风险评分（CSRS），以确定其预测 30 天内未在指数 ED 评估中显现的严重结局的能力。
设计、地点和参与者：这项在加拿大 9 个急诊科进行的前瞻性多中心队列研究纳入了在晕厥后 24 小时内就诊于急诊科的 16 岁及以上患者。患者于 2014 年 3 月至 2018 年 4 月入组。
收集了基线特征、CSRS 预测因子和 30 天经裁决的严重结局，包括心律失常（心律失常、心律失常干预或死因不明）和非心律失常（心肌梗死、结构性心脏病、肺栓塞或出血）严重结局。计算了 CSRS 验证的校准和区分特征。
共纳入 3819 例患者（平均[SD]年龄 53.9[22.8]岁；2088[54.7%]为女性），其中 139 例（3.6%）发生 30 天严重结局，包括 13 例（0.3%）死亡。在验证队列中，预测风险与观察风险之间无差异，校准斜率为 1.0，接受者操作特征曲线下面积为 0.91（95%CI，0.88-0.93）。验证期间 30 天严重结局的经验概率为 3.64%（95%CI，3.09%-4.28%），而模型预测概率为 3.17%（95%CI，2.66%-3.77%；P=0.26）。随着 CSRS 风险级别的增加，30 天严重结局患者的比例从极低风险组的 3 例（1631 例中的 0.3%）增加到极高风险组的 40 例（78 例中的 51.3%）（Cochran-Armitage 趋势检验 P<0.001）。随着 CSRS 风险类别的增加，严重结局亚型也有类似的显著增加。极低风险和低风险患者中无一例死亡或出现室性心律失常。在阈值评分-1（3819 例患者中的 2145 例）时，CSRS 的灵敏度和特异性分别为 97.8%（95%CI，93.8%-99.6%）和 44.3%（95%CI，42.7%-45.9%）。
CSRS 得到了成功验证，建议在 ED 评估期间未发现严重病因时使用该评分来指导 ED 管理。极低风险和低风险患者通常可以出院，而高风险患者可考虑短暂住院。我们相信 CSRS 的实施有潜力提高患者安全性和医疗效率。
