Ver el código de «EBQ:San Francisco Syncope Rule»

{{JC info
| title= Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes
| abbreviation= 
| expansion=
| published= 2006 May
| author= Quinn J. et al. 
| journal= Ann Emerg Med
| year= 2006
| volume= 31
| issue=26
| pages= 2992-6
| pmid= 16631985
| fulltexturl= http://www.sciencedirect.com.journals.labiomed.org/science/article/pii/S0196064405019591
| pdfurl=http://theddx.org/papers/San_Francisco_syncope.pdf
| status=Complete
}}
==Clinical Question==
Can the San Francisco Syncope Rule be used in clinical practice to risk stratify patients presenting with syncope?

==Conclusion==
*The San Francisco Syncope Rule demonstrated to be highly sensitive (98% sensitivity, 95% CI 89-100%) but not very specific (56%, 95% CI 52-60%) for predicting serious outcomes.

==Major Points==
{{San Francisco Syncope Rule}}
The rule is positive if any of the above apply to the patient.

==Study Design==
*A prospective cohort study 
*N =: 760 patients had 791 visits for syncope (1.2% of all ED visits)
*Consecutive patients with syncope or near syncope presenting to an emergency department of a large, urban teaching hospital were identified and enrolled from July 15, 2002 to August 31, 2004
*Physicians prospectively applied the San Francisco Syncope Rule
**Patient follow up performed to determine if the patient suffered a predefined serious outcome within 30 days of their ED visit
**Physicians completed a short Web-based form and enrolled patients after their assessment
**Study investigators reviewed all data forms in order to ensure the correct interpretation of the rule
*30 day follow-up completed after patients' index ED visit to determine short-term outcomes that would require admission
**Short-term serious outcomes defined as:
***Death
***Myocardial Infarction
****Any elevation of troponin or ECG change with an accompanying diagnosis of myocardial infarction on D/C and confirmed by the cardiology service or primary physician
***Arrhythmia
***Pulmonary Embolism
****Needed to have received treatment for the pulmonary embolism or had it confirmed on autopsy
***Stoke
***Subarachnoid Hemorrhage
***Significant Hemorrhage or Anemia Requiring Transfusion
***Procedural intervention to treat a related cause of syncope or any condition causing or likely to cause a return ED visit
***Hospitalization for a related event

==Population==
===Patient Demographics===
*364 men, 427 females
*Mean age: 61
*Admitted: 469 (59%)
*Patients with serious outcomes after ED visit: 54 (6.8%)
**Death: 3
**Arrhythmia: 23
**Myocardial Infarction: 11
**Valvular Heart Disease: 1
**Significant Hemorrhage: 7
**TIA/Stroke: 3
**Sepsis: 3
**Admission after ED Discharge : 3

===Inclusion Criteria===
*Consecutive patients presenting with syncope or near syncope without any of the predefined exclusion criteria

===Exclusion Criteria===
*Trauma-related loss of consciousness
*Alcohol-related loss of consciousness
*Drug-related loss of consciousness
*Definite seizure
*LOC associated with an altered level of consciousness or persistent new neurologic deficits did not meet operational definition of syncope and were excluded

==Interventions== 
 
==Outcomes==
*30 day follow-up after the patients' index ED visit to determine serious short-term outcomes
*Serious short-term outcomes defined as: death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage or anemia requiring transfusion, procedural intervention to treat a related cause of syncope or any condition likely to cause a return ED visit, and hospitalization for a related event
===Primary Outcome===
*Patients with serious outcomes after ED visit: 54 (6.8%)
'''Performance of the San Francisco Syncope Rule in the validation cohort'''
{| class="wikitable"
|-
! Decision Rule !! Yes !! No
|-
| Rule Positive || 52 || 290
|-
| Rule Negative || 1 || 370
|}
*Sensitivity 98% (95% CI 89% to 100%)
*Specificity 56% (95% CI 52% to 60%)
*Negative Predictive Value 99.7% (95% CI 98% to 100%)
*Positive Predictive Value 15% (95% CI 12% to 20%)
*Death: 3
*Arrhythmia: 23
*Myocardial Infarction: 11
*Valvular Heart Disease: 1
*Significant Hemorrhage: 7
*TIA/Stroke: 3
*Sepsis: 3
*Admission after ED discharge: 3

===Secondary Outcomes=== 
*Physicians accurately interpreted the rule 95% of the time
**Physicians felt comfortable using the rule in 79% of the cases
**Physicians felt neutral using the rule in 15% of cases
**Physicians felt uncomfortable using the rule in 6% of cases
*The San Francisco Syncope Rule would have classified 52% of the patients as high risk
**Using the rule potentially would have decreased overall admissions by 7%
**Applying the rule to only the 453 patients admitted might have decreased admissions by 24%
===Subgroup analysis===

==Criticisms & Further Discussion==
*Patients from only one hospital enrolled in the study
*Validation study is performed at the same center used to derive the original rule
*Wide margin of error observed in sensitivity<ref>Miller C, Hoekstra J. Prospective Validation of the San Francisco Syncope Rule: Will It Change Practice? Ann Emerg Med. 2006 May;47(5):455-56. PubMed PMID: 16631986</ref>
**98% [95% confidence interval 89% to 100%). Taking the lower limit of the confidence interval as the correct value, the clinical decision rule cannot be considered highly sensitive
***For example, in 100 patients with syncope of undetermined cause on presentation, 11 discharged home could have an adverse outcome
*54 patients has serious outcomes, but only 53 patients had data forms prospectively completed. The patient without a data form was excluded from the sensitivity analysis

==Funding==
*A career development grant from the National Institutes of Health available to Dr. James Quinn, MD, MS, primary investigator of the study

==Further Reading==
[http://www.acep.org/Clinical---Practice-Management/Clinical-Policy--Management-of-Syncope/ ACEP Clinical Practice Management: Management of Syncope]
{{JC info
| title= Risk stratification of patients with syncope
| abbreviation= 
| expansion=
| published=
| author= Martin TP et al. 
| journal= Ann Emerg Med
| year= 1997
| volume= 29
| issue=
| pages= 459-466
| pmid= 9095005
| fulltexturl=
| pdfurl=
| status=Complete
}}
{{JC info
| title= Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score
| abbreviation= 
| expansion=
| published=
| author= Colivicchi F et al
| journal= Eur Heart J.
| year= 2003
| volume= 24
| issue=
| pages= 811-819
| pmid= 12727148
| fulltexturl= 
| pdfurl=
| status=Complete
}}
{{JC info
| title= A risk score to predict arrhythmias in patients with unexplained syncope
| abbreviation= 
| expansion=
| published=
| author= Sarasin FP, Hanusa BH, Perneger T, et al.
| journal= Acad Emerg Med
| year= 2003
| volume= 10
| issue=
| pages= 1312-1317
| pmid= 14644781
| fulltexturl= 
| pdfurl=
| status=Complete
}}

==See Also==
*[[Syncope]]

==References==
<references/>

[[Category:EBQ]]
[[Category:Neurology]]
[[Category:Cardiology]]