Predicting short-term adverse outcomes in the geriatric population presenting with syncope: a comparison of existing syncope rules and beyond

Suud A Kiradoh; Timothy E Craven; Maria O Rangel; Lillian M Nosow; Erfan Zarrinkhoo; Suma Menon; Parag A Chevli; Tareq M Islam; Luqman A Thazhatuveetil-Kunhahamed

doi:10.26599/1671-5411.2023.01.008

Predicting short-term adverse outcomes in the geriatric population presenting with syncope: a comparison of existing syncope rules and beyond

J Geriatr Cardiol. 2023 Jan 28;20(1):11-22. doi: 10.26599/1671-5411.2023.01.008.

Authors

Suud A Kiradoh¹, Timothy E Craven², Maria O Rangel³, Lillian M Nosow¹, Erfan Zarrinkhoo¹, Suma Menon¹, Parag A Chevli¹, Tareq M Islam¹, Luqman A Thazhatuveetil-Kunhahamed¹

Affiliations

¹ Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA.
² Biostatistics, Epidemiology, Research, and Design (BERD), Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA.
³ Department of Cardiology, Atrium Health Wake Forest Baptist Medical Center, USA.

Abstract

Objectives: Syncope at age 65+ is associated with increased mortality, irrespective of cause. Syncope rules were designed to aid in risk-stratification but were only validated in the general adult population. Our objective was to determine if they can be applied to a geriatric population in predicting short-term adverse outcomes.

Methods: In this single-center retrospective study, we evaluated 350 patients aged 65+ presenting with syncope. Exclusion criteria included confirmed non-syncope, active medical condition, drug or alcohol-related syncope. Patients were stratified into high or low risk based on Canadian Syncope Risk Score (CSRS), Evaluation of Guidelines in Syncope Study (EGSYS), San Francisco Syncope Rule (SFSR), and Risk Stratification of Syncope in the Emergency Department (ROSE). Composite adverse outcomes at 48-hour and 30-day included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), return emergency department visit, hospitalization, or medical intervention. We assessed each score's ability to predict the outcomes using logistic-regression and compared performances using receiver-operator curves. Multivariate analyses were performed to study the associations between recorded parameters and outcomes.

Results: CSRS outperformed with AUC of 0.732 (95% CI: 0.653-0.812) and 0.749 (95% CI: 0.688-0.809) for 48-h and 30-day outcomes, respectively. Sensitivities for CSRS, EGSYS, SFSR, and ROSE for 48-hour outcomes were 48%, 65%, 42% and 19%; and for 30-day outcomes were 72%, 65%, 30% and 55%, respectively. Atrial fibrillation/flutter on EKG, congestive heart failure, antiarrhythmics, systolic blood-pressure < 90 at triage, and associated chest pain highly correlated with 48-h outcomes. An EKG abnormality, heart disease history, severe pulmonary hypertension, BNP > 300, vasovagal predisposition, and antidepressants highly correlated with 30-day outcomes.

Conclusions: Performance and accuracy of four prominent syncope rules were suboptimal in identifying high-risk geriatric patients with short-term adverse outcomes. We identified some significant clinical and laboratory information that may play a role in predicting short-term adverse events in a geriatric cohort.