International Validation of the Canadian Syncope Risk Score : A Cohort Study

doi:10.7326/M21-2313

Multicenter Study

. 2022 Jun;175(6):783-794.

doi: 10.7326/M21-2313. Epub 2022 Apr 26.

International Validation of the Canadian Syncope Risk Score : A Cohort Study

Tobias Zimmermann¹, Jeanne du Fay de Lavallaz², Thomas Nestelberger³, Danielle M Gualandro⁴, Pedro Lopez-Ayala², Patrick Badertscher², Velina Widmer⁵, Samyut Shrestha², Ivo Strebel², Noemi Glarner⁵, Matthias Diebold², Òscar Miró⁶, Michael Christ⁷, Louise Cullen⁸, Martin Than⁹, F Javier Martin-Sanchez¹⁰, Salvatore Di Somma¹¹, W Frank Peacock¹², Dagmar I Keller¹³, Murat Bilici¹⁴, Juan Pablo Costabel¹⁵, Michael Kühne², Tobias Breidthardt¹⁶, Venkatesh Thiruganasambandamoorthy¹⁷, Christian Mueller²; BASEL IX Investigators†; Maria Belkin, Kathrin Leu, Jens Lohrmann, Jasper Boeddinghaus, Raphael Twerenbold, Luca Koechlin, Joan E Walter, Melissa Amrein, Desiree Wussler, Michael Freese, Christian Puelacher, Damian Kawecki, Beata Morawiec, Emilio Salgado, Gemma Martinez-Nadal, Carolina Isabel Fuenzalida Inostroza, José Bustamante Mandrión, Imke Poepping, Katharina Rentsch, Arnold von Eckardstein, Andreas Buser, Jaimi Greenslade, Tobias Reichlin, Franz Bürgler

Collaborators, Affiliations

Affiliations

¹ Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.Z.).
² Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.).
³ Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.N.).
⁴ Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil (D.M.G.).
⁵ Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.).
⁶ GREAT Network, Rome, Italy, and Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.).
⁷ GREAT Network, Rome, Italy, and Kantonsspital Luzern, Luzern, Switzerland (M.C.).
⁸ GREAT Network, Rome, Italy, and Royal Brisbane & Women's Hospital, Herston, Australia (L.C.).
⁹ GREAT Network, Rome, Italy, and Christchurch Hospital, Christchurch, New Zealand (M.T.).
¹⁰ GREAT Network, Rome, Italy, and Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.).
¹¹ GREAT Network, Rome, Italy, and Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Italy (S.D.S.).
¹² GREAT Network, Rome, Italy, and Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas (W.F.P.).
¹³ Emergency Department, University Hospital Zürich, Zürich, Switzerland (D.I.K.).
¹⁴ Department of Orthopedics and Traumatology, University Hospital Basel, University of Basel, Basel, Switzerland (M.B.).
¹⁵ Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina (J.P.C.).
¹⁶ Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.B.).
¹⁷ Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada (V.T.).

PMID: 35467933
DOI: 10.7326/M21-2313

Multicenter Study

International Validation of the Canadian Syncope Risk Score : A Cohort Study

Tobias Zimmermann et al. Ann Intern Med. 2022 Jun.

. 2022 Jun;175(6):783-794.

doi: 10.7326/M21-2313. Epub 2022 Apr 26.

Authors

Affiliations

¹ Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.Z.).
² Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.).
³ Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.N.).
⁴ Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil (D.M.G.).
⁵ Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.).
⁶ GREAT Network, Rome, Italy, and Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.).
⁷ GREAT Network, Rome, Italy, and Kantonsspital Luzern, Luzern, Switzerland (M.C.).
⁸ GREAT Network, Rome, Italy, and Royal Brisbane & Women's Hospital, Herston, Australia (L.C.).
⁹ GREAT Network, Rome, Italy, and Christchurch Hospital, Christchurch, New Zealand (M.T.).
¹⁰ GREAT Network, Rome, Italy, and Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.).
¹¹ GREAT Network, Rome, Italy, and Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Italy (S.D.S.).
¹² GREAT Network, Rome, Italy, and Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas (W.F.P.).
¹³ Emergency Department, University Hospital Zürich, Zürich, Switzerland (D.I.K.).
¹⁴ Department of Orthopedics and Traumatology, University Hospital Basel, University of Basel, Basel, Switzerland (M.B.).
¹⁵ Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina (J.P.C.).
¹⁶ Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.B.).
¹⁷ Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada (V.T.).

PMID: 35467933
DOI: 10.7326/M21-2313

Abstract

Background: The Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes not evident during emergency department (ED) evaluation.

Objective: To externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score.

Design: Prospective cohort study.

Setting: Large, international, multicenter study recruiting patients in EDs in 8 countries on 3 continents.

Participants: Patients with syncope aged 40 years or older presenting to the ED within 12 hours of syncope.

Measurements: Composite outcome of serious clinical plus procedural events (primary outcome) and the primary composite outcome excluding procedural interventions (secondary outcome).

Results: Among 2283 patients with a mean age of 68 years, the primary composite outcome occurred in 7.2%, and the composite outcome excluding procedural interventions occurred in 3.1% at 30 days. Prognostic performance of the CSRS was good for both 30-day composite outcomes and better compared with the OESIL score (area under the receiver-operating characteristic curve [AUC], 0.85 [95% CI, 0.83 to 0.88] vs. 0.74 [CI, 0.71 to 0.78] and 0.80 [CI, 0.75 to 0.84] vs. 0.69 [CI, 0.64 to 0.75], respectively). Safety of triage, as measured by the frequency of the primary composite outcome in the low-risk group, was higher using the CSRS (19 of 1388 [0.6%]) versus the OESIL score (17 of 1104 [1.5%]). A simplified model including only the clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) variable at ED discharge-a component of the CSRS-achieved similar discrimination as the CSRS (AUC, 0.83 [CI, 0.80 to 0.87] for the primary composite outcome).

Limitation: Unable to disentangle the influence of other CSRS components on clinician classification of syncope at ED discharge.

Conclusion: This international external validation of the CSRS showed good performance in identifying patients at low risk for serious outcomes outside of Canada and superior performance compared with the OESIL score. However, clinician classification of syncope at ED discharge seems to explain much of the performance of the CSRS in this study. The clinical utility of the CSRS remains uncertain.

Primary funding source: Swiss National Science Foundation & Swiss Heart Foundation.

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Comment in

Syncope in the Emergency Department: Should We Be Using the Canadian Syncope Risk Score?: July 2023 Annals of Emergency Medicine Journal Club.
Moss L, Propersi ME, Karounos M. Moss L, et al. Ann Emerg Med. 2023 Jul;82(1):115-117. doi: 10.1016/j.annemergmed.2023.05.023. Ann Emerg Med. 2023. PMID: 37349069 No abstract available.

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Furlan L, Jacobitti Esposito G, Gianni F, Solbiati M, Mancusi C, Costantino G. Furlan L, et al. J Clin Med. 2024 May 30;13(11):3231. doi: 10.3390/jcm13113231. J Clin Med. 2024. PMID: 38892942 Free PMC article. Review.
A Hybrid Model for 30-Day Syncope Prognosis Prediction in the Emergency Department.
Dipaola F, Gatti M, Menè R, Shiffer D, Giaj Levra A, Solbiati M, Villa P, Costantino G, Furlan R. Dipaola F, et al. J Pers Med. 2023 Dec 20;14(1):4. doi: 10.3390/jpm14010004. J Pers Med. 2023. PMID: 38276219 Free PMC article.
Impact of Admission of Patients With Syncope in Non-Teaching Hospitals Versus Teaching Hospitals: A Nationwide Analysis.
Malik M, Francis-Morel G. Malik M, et al. Cureus. 2023 May 26;15(5):e39545. doi: 10.7759/cureus.39545. eCollection 2023 May. Cureus. 2023. PMID: 37378229 Free PMC article.
Arrhythmic syncope: From diagnosis to management.
Francisco Pascual J, Jordan Marchite P, Rodríguez Silva J, Rivas Gándara N. Francisco Pascual J, et al. World J Cardiol. 2023 Apr 26;15(4):119-141. doi: 10.4330/wjc.v15.i4.119. World J Cardiol. 2023. PMID: 37124975 Free PMC article. Review.

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International Validation of the Canadian Syncope Risk Score : A Cohort Study

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International Validation of the Canadian Syncope Risk Score : A Cohort Study

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