Wakai Abel, Sinert Richard, Zehtabchi Shahriar, Souza Ian S de, Benabbas Roshanak, Allen Robert, Dunne Eric, Richards Rebekah, Ardilouze Amelie, Rovic Isidora
Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland.
Emergency Care Research Unit (ECRU), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland.
Acad Emerg Med. 2025 Jan;32(1):72-86. doi: 10.1111/acem.15041. Epub 2024 Nov 4.
Approximately 10% of patients with syncope have serious or life-threatening causes that may not be apparent during the initial emergency department (ED) assessment. Consequently, researchers have developed clinical decision rules (CDRs) to predict adverse outcomes and risk stratify ED syncope patients. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the methodological quality and predictive accuracy of CDRs for developing an evidence-based ED syncope management guideline.
We conducted a systematic literature search according to the patient-intervention-control-outcome question: In patients 16 years of age or older who present to the ED with syncope for whom no underlying serious/life-threatening condition was found during the index ED visit (population), are risk stratification tools (intervention), better than unstructured clinical judgment (i.e., usual care; comparison), for providing accurate prognosis and aiding disposition decision for outcomes within 30 days (outcome)? Two reviewers independently assessed articles for inclusion and methodological quality. We performed statistical analysis using Meta-DiSc. We used GRADEPro GDT software to determine the certainty of the evidence and create a summary of the findings (SoF) tables.
Of 2047 publications obtained through the search strategy, 31 comprising 13 CDRs met the inclusion criteria. There were 13 derivation studies (17,578 participants) and 24 validation studies (14,845 participants). Only three CDRs were validated in more than two studies. The San Francisco Syncope Rule (SFSR) was validated in 12 studies: positive likelihood ratio (LR+) 1.15-4.70 and negative likelihood ratio (LR-) 0.03-0.64. The Canadian Syncope Risk Score (CSRS) was validated in five studies: LR+ 1.15-2.58 and LR- 0.05-0.50. The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score was validated in five studies: LR+ 1.16-3.32 and LR- 0.14-0.46.
Most CDRs for ED adult syncope management have low-quality evidence for routine clinical practice use. Only three CDRs (SFSR, CSRS, OESIL) are validated by more than two studies, with significant overlap in operating characteristics.
约10%的晕厥患者有严重或危及生命的病因，在急诊科（ED）初始评估时可能并不明显。因此，研究人员制定了临床决策规则（CDR）来预测不良结局并对ED晕厥患者进行风险分层。本系统评价和荟萃分析（SRMA）旨在整合和综合当前关于CDR的方法学质量和预测准确性的最佳证据，以制定基于证据的ED晕厥管理指南。
我们根据患者-干预-对照-结局问题进行了系统的文献检索：在16岁及以上因晕厥就诊于ED且在首次ED就诊期间未发现潜在严重/危及生命疾病的患者（人群）中，风险分层工具（干预）是否比非结构化临床判断（即常规护理；对照）在提供准确预后和辅助30天内结局处置决策方面更优（结局）？两名评审员独立评估文章的纳入情况和方法学质量。我们使用Meta-DiSc进行统计分析。我们使用GRADEPro GDT软件确定证据的确定性并创建结果总结（SoF）表。
通过检索策略获得的2047篇出版物中，31篇包含13个CDR符合纳入标准。有13项推导研究（17578名参与者）和24项验证研究（14845名参与者）。只有3个CDR在两项以上研究中得到验证。旧金山晕厥规则（SFSR）在12项研究中得到验证：阳性似然比（LR+）为1.15 - 4.70，阴性似然比（LR-）为0.03 - 0.64。加拿大晕厥风险评分（CSRS）在5项研究中得到验证：LR+为1.15 - 2.58，LR-为0.05 - 0.5这两项研究中得到验证：LR+为1.16 - 3.32，LR-为0.14 - 0.46。
大多数用于ED成人晕厥管理的CDR在常规临床实践中的证据质量较低。只有3个CDR（SFSR、CSRS、OESIL）在两项以上研究中得到验证，其操作特征有显著重叠。
