Practical Approaches to Care in Emergency Syncope
Practical Approaches to Care in Emergency Syncope
Syncope, or transient loss of consciousness, is a common reason for visit to the Emergency
 Department and often leads to extensive testing and hospitalization. Using objective risk
 scores to determine which patients with syncope will actually benefit from these
 interventions, and which can be safely discharged home with minimal testing, is critical to
 providing sensible medical care. This study will evaluate the validity of two syncope
 risk-stratification tools and investigate their impact on healthcare utilization and patient
 safety, thus improving the quality of care for the 1-2 million patients who experience
 syncope every year in the United States
The goal of this project is to improve risk-stratification for patients who present to the
 emergency department (ED) with syncope (transient loss of consciousness), in order to better
 delineate which patients require admission and which can be safely discharged home. Syncope
 and pre-syncope (the sensation of impending loss of consciousness) are common reasons to
 present to the ED, representing over 1.3 million visits per year in the United States.

 Although syncope is most often benign, it can occasionally be caused by serious
 cardiopulmonary diseases such as cardiac arrhythmia, acute coronary syndrome, or pulmonary
 embolism. Despite thorough evaluation in the ED, the cause of syncope remains unknown in over
 50% of cases, which leads to a large number of syncope patients being admitted for
 observation and/or further testing. These admissions to the hospital or observation unit are
 low-yield, costly, and expose patients to the possibility of iatrogenic harm.

 In response to this, two groups of researchers have developed distinct syncope
 risk-stratification tools: the US Syncope Risk Score (FAINT) and the Canadian Syncope Risk
 Score. These scores use a combination of clinical, electrocardiographic, and laboratory
 variables to predict the risk of serious clinical outcomes at 30 days. While promising, these
 two risk scores require external validation prior to widespread clinical implementation. The
 study team will prospectively collect data on ~1,270 ED patients with syncope/pre-syncope and
 follow them for 30 days to validate the predictive accuracy of these two risk scores. The
 study team will then assess the impact of implementing these scores by measuring their
 potential effect on healthcare utilization and costs.

 If validated and shown to safely reduce healthcare utilization, these syncope risk scores
 could play a major role in improving emergency syncope care by reducing low-yield admissions
 and identifying patients who are unsafe for discharge from the ED. This study, entitled
 PACES: Practical Approaches to Care in Emergency Syncope, will help increase the quality and
 value of emergency care, and advance the field of syncope research.
Inclusion Criteria:

 -  Adult patients 40 years of age or older who present to the Emergency Department with
 syncope or presyncope.

 -  Subjects must read and speak English or Spanish.

 -  Subjects must have a working phone number and fixed address.

 Exclusion Criteria:

 -  Patient who have a syncope mimic such as seizure, stroke, head trauma with loss of
 consciousness, altered mental status, hypoglycemia, intoxication, or require an
 intervention to restore consciousness.

 -  Patients who have a new serious diagnosis found in the Emergency Department, such as
 death, significant cardiac arrhythmia (see below), myocardial infarction, significant
 structural heart disease, stroke (both ischemic and hemorrhagic), pulmonary embolism,
 aortic dissection, hemorrhage or anemia requiring blood transfusion, subarachnoid
 hemorrhage, cardiopulmonary resuscitation, acute surgical illness, pregnancy, or major
 traumatic injury.

 -  Significant cardiac arrhythmia includes Ventricular Fibrillation, Ventricular
 tachycardia (>30 secs), Symptomatic ventricular tachycardia, (<30 secs), Sick sinus
 disease with alternating sinus bradycardia and tachycardia, Sinus pause > 3 seconds,
 Mobitz type II atrioventricular heart block, Complete heart block, Symptomatic
 supraventricular tachycardia (including PSVT, rapid atrial fibrillation/ flutter),
 Symptomatic bradycardia (pulse<40), Pacemaker or implantable
 cardioverter-defibrillator malfunction with cardiac pauses.