Albassam OT, Redelmeier RJ, Shadowitz S, et al. Did This Patient Have Cardiac Syncope?: The Rational Clinical Examination Systematic Review. JAMA. 2019 Jun 25;321(24):2448-2457. doi: 10.1001/jama.2019.8001. (Systematic review)

Importance: Syncope can result from a reduction in cardiac output from serious cardiac conditions, such as arrhythmias or structural heart disease (cardiac syncope), or other causes, such as vasovagal syncope or orthostatic hypotension.

Objective: To perform a systematic review of studies of the accuracy of the clinical examination for identifying patients with cardiac syncope.

Study Selection: Studies of adults presenting to primary care, emergency departments, or referred to specialty clinics.

Data Extraction and Synthesis: Relevant data were abstracted from articles in databases through April 9, 2019, and methodologic quality was assessed. Included studies had an independent comparison to a reference standard.

Main Outcomes and Measures: Sensitivity, specificity, and likelihood ratios (LRs).

Results: Eleven studies of cardiac syncope (N = 4317) were included. Age at first syncope of at least 35 years was associated with greater likelihood of cardiac syncope (n = 323; sensitivity, 91% [95% CI, 85%-97%]; specificity, 72% [95% CI, 66%-78%]; LR, 3.3 [95% CI, 2.6-4.1]), while age younger than 35 years was associated with a lower likelihood (LR, 0.13 [95% CI, 0.06-0.25]). A history of atrial fibrillation or flutter (n = 323; sensitivity, 13% [95% CI, 6%-20%]; specificity, 98% [95% CI, 96%-100%]; LR, 7.3 [95% CI, 2.4-22]), or known severe structural heart disease (n = 222; range of sensitivity, 35%-51%, range of specificity, 84%-93%; range of LR, 3.3-4.8; 2 studies) were associated with greater likelihood of cardiac syncope. Symptoms prior to syncope that were associated with lower likelihood of cardiac syncope were mood change or prodromal preoccupation with details (n = 323; sensitivity, 2% [95% CI, 0%-5%]; specificity, 76% [95% CI, 71%-81%]; LR, 0.09 [95% CI, 0.02-0.38]), feeling cold (n = 412; sensitivity, 2% [95% CI, 0%-5%]; specificity, 89% [95% CI, 85%-93%]; LR, 0.16 [95% CI, 0.06-0.64]), or headache (n = 323; sensitivity, 3% [95% CI, 0%-7%]; specificity, 80% [95% CI, 75%-85%]; LR, 0.17 [95% CI, 0.06-0.55]). Cyanosis witnessed during the episode was associated with higher likelihood of cardiac syncope (n = 323; sensitivity, 8% [95% CI, 2%-14%]; specificity, 99% [95% CI, 98%-100%]; LR, 6.2 [95% CI, 1.6-24]). Mood changes after syncope (n = 323; sensitivity, 3% [95% CI, 0%-7%]; specificity, 83% [95% CI, 78%-88%]; LR, 0.21 [95% CI, 0.06-0.65]) and inability to remember behavior prior to syncope (n = 323; sensitivity, 5% [95% CI, 0%-9%]; specificity, 82% [95% CI, 77%-87%]; LR, 0.25, [95% CI, 0.09-0.69]) were associated with lower likelihood of cardiac syncope. Two studies prospectively validated the accuracy of the multivariable Evaluation of Guidelines in Syncope Study (EGSYS) score, which is based on 6 clinical variables. An EGSYS score of less than 3 was associated with lower likelihood of cardiac syncope (n = 456; range of sensitivity, 89%-91%, range of specificity, 69%-73%; range of LR, 0.12-0.17; 2 studies). Cardiac biomarkers show promising diagnostic accuracy for cardiac syncope, but diagnostic thresholds require validation.

Conclusions and Relevance: The clinical examination, including the electrocardiogram as part of multivariable scores, can accurately identify patients with and without cardiac syncope.

Discipline Area Score
Hospital Doctor/Hospitalists 7 / 7
Internal Medicine 7 / 7
Emergency Medicine 5 / 7
Cardiology 4 / 7
General Internal Medicine-Primary Care(US) Coming Soon...
Family Medicine (FM)/General Practice (GP) Coming Soon...
Comments from MORE raters

Cardiology rater

This is a welcome meta-analysis of a very common problem in emergency rooms. The heuristic of experienced cardiologists works well in the identification of dangerous syncopes, but they have difficulties to transmit to students and residents their skills. Besides to present the state-of-art, this manuscript is going to be a valuable tool to diagnose and to teach how to diagnose cardiac syncopes in ERs.

Emergency Medicine rater

This is a review of studies about the accuracy of various aspects of the clinical exam (mostly the interpretation of history items) for predicting the diagnosis of syncope of cardiac origin. This is information most emergency physicians probably know. However, it is a nice summary of the topic and therefore potentially of use to practicing emergency physicians.
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