Skip to main content
Log in

Prognostic value of cardiac biomarkers in the risk stratification of syncope: a systematic review

  • EM - ORIGINAL
  • Published:
Internal and Emergency Medicine Aims and scope Submit manuscript

Abstract

The role of cardiac biomarkers in risk stratification of syncope is unclear. We undertook a systematic review to assess their predictive value for short-term major adverse cardiovascular events (MACE). We conducted a systematic review using MEDLINE, EMBASE, DARE and Cochrane databases from inception to July 2014. We included studies involving adult syncope patients that evaluated cardiac biomarker levels for risk stratification during acute management and excluded case reports, reviews and studies involving children. Primary outcome (MACE) included death, cardiopulmonary resuscitation, myocardial infarction (MI), structural heart disease, pulmonary embolism, significant hemorrhage or cardiac procedural interventions. Secondary outcome analysis assessed for prediction of MI, cardiac syncope and death. Two reviewers extracted patient-level data based on the cut-off reported. Pooled sensitivities and specificities were calculated using patient-level data. A total of 1862 articles were identified, and 11 studies with 4246 patients were included. Studies evaluated 3 biomarkers: contemporary troponin (2693 patients), natriuretic peptides (1353 patients) and high-sensitive troponin (819 patients). The pooled sensitivities and specificities for MACE were: contemporary troponin 0.29 (95 % CI 0.24, 0.34) and 0.88 (95 % CI 0.86, 0.89); natriuretic peptides 0.77 (95 % CI 0.69, 0.85) and 0.73 (95 % CI 0.70, 0.76); high-sensitive troponin 0.74 (95 % CI 0.65, 0.83) and 0.65 (95 % CI 0.62, 0.69), respectively. Natriuretic peptides and high-sensitive troponin showed good diagnostic characteristics for both primary and secondary outcomes. Natriuretic peptides and high-sensitive troponin might be useful in risk stratification.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Moya A, Sutton R, Ammirati F et al (2009) Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 30(21):2631–71 (Epub 2009 Aug 27. 2009; 30)

  2. Soteriades ES, Evans JC, Larson MG et al (2002) Incidence and prognosis of syncope. N Engl J Med 347:878–885

    Article  PubMed  Google Scholar 

  3. Blanc JJ, L’Her C, Touiza A, Garo B, L’Her E, Mansourati J (2002) Prospective evaluation and outcome of patients admitted for syncope over a 1 year period. Eur Heart J 23:815–820

    Article  PubMed  Google Scholar 

  4. Sarasin FP, Louis-Simonet M, Carballo D et al (2001) Prospective evaluation of patients with syncope: a population-based study. Am J Med 111:177–184

    Article  CAS  PubMed  Google Scholar 

  5. Sun BC, Emond JA, Camargo CA Jr (2004) Characteristics and admission patterns of patients presenting with syncope to U.S. emergency departments, 1992–2000. Acad Emerg Med 11:1029–1034

    PubMed  Google Scholar 

  6. Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA (2004) Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med 43:224–232

    Article  PubMed  Google Scholar 

  7. Thiruganasambandamoorthy V, Hess EP, Turko E, Perry JJ, Wells GA, Stiell IG (2013) Outcomes in Canadian emergency department syncope patients—are we doing a good job? J Emerg Med 44:321–328

    Article  PubMed  Google Scholar 

  8. Sun BC, Mangione CM, Merchant G et al (2007) External validation of the San Francisco Syncope Rule. Ann Emerg Med 49:420–427

    Article  PubMed  Google Scholar 

  9. Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ (2008) Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med 52:151–159

    Article  PubMed  Google Scholar 

  10. Thiruganasambandamoorthy V, Hess EP, Alreesi A, Perry JJ, Wells GA, Stiell IG (2010) External validation of the San Francisco Syncope rule in the Canadian setting. Ann Emerg Med 55:464–472

    Article  PubMed  Google Scholar 

  11. Reed MJ, Newby DE, Coull AJ, Prescott RJ, Jacques KG, Gray AJ (2010) The ROSE (risk stratification of syncope in the emergency department) study. J Am Coll Cardiol 55:713–721

    Article  CAS  PubMed  Google Scholar 

  12. Grossman SA, Fischer C, Lipsitz LA et al (2007) Predicting adverse outcomes in syncope. J Emerg Med 33:233–239

    Article  PubMed Central  PubMed  Google Scholar 

  13. Costantino G, Perego F, Dipaola F et al (2008) Short- and long-term prognosis of syncope, risk factors, and role of hospital admission: results from the STePS (Short-Term Prognosis of Syncope) study. J Am Coll Cardiol 51:276–283

    Article  PubMed  Google Scholar 

  14. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3:25

    Article  PubMed Central  PubMed  Google Scholar 

  15. Whiting PF, Weswood ME, Rutjes AW, Reitsma JB, Bossuyt PN, Kleijnen J (2006) Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies. BMC Med Res Methodol 6:9

    Article  PubMed Central  PubMed  Google Scholar 

  16. Hing R, Harris R (2005) Relative utility of serum troponin and the OESIL score in syncope. Emerg Med Australas 17:31–38

    Article  PubMed  Google Scholar 

  17. Chiu DT, Shapiro NI, Sun BC, Mottley JL, Grossman SA (2014) Are echocardiography, telemetry, ambulatory electrocardiography monitoring, and cardiac enzymes in emergency department patients presenting with syncope useful tests? A preliminary investigation. J Emerg Med 47:113–118

    Article  PubMed  Google Scholar 

  18. Sun BC, Derose SF, Liang LJ et al (2009) Predictors of 30-day serious events in older patients with syncope. Ann Emerg Med 54:769–778.e1-5

  19. Reed MJ, Newby DE, Coull AJ, Prescott RJ, Gray AJ (2010) Diagnostic and prognostic utility of troponin estimation in patients presenting with syncope: a prospective cohort study. Emerg Med J 27:272–276

    Article  PubMed  Google Scholar 

  20. Tanimoto K, Yukiiri K, Mizushige K et al (2004) Usefulness of brain natriuretic peptide as a marker for separating cardiac and noncardiac causes of syncope. Am J Cardiol 93:228–230

    Article  CAS  PubMed  Google Scholar 

  21. Reed MJ, Newby DE, Coull AJ, Jacques KG, Prescott RJ, Gray AJ (2007) Role of brain natriuretic peptide (BNP) in risk stratification of adult syncope. Emerg Med J 24:769–773

    Article  PubMed Central  PubMed  Google Scholar 

  22. Pfister R, Hagemeister J, Esser S, Hellmich M, Erdmann E, Schneider CA (2012) NT-pro-BNP for diagnostic and prognostic evaluation in patients hospitalized for syncope. Int J Cardiol 155:268–272

    Article  PubMed  Google Scholar 

  23. Christ M, Geier F, Popp S et al (2015) Diagnostic and prognostic value of cTnT high-sensitive in patients with syncope. Am J Med 128:161–170

    Article  CAS  PubMed  Google Scholar 

  24. Lindner G, Pfortmueller C, Funk G, Leichtle A, Fiedler G, Exadaktylos A High-sensitive troponin measurement in emergency department patients presenting with syncope: a retrospective analysis. PLoS One [Electronic Resource] 8:e66470

  25. Reed MJ, Mills NL, Weir CJ (2012) Sensitive troponin assay predicts outcome in syncope. Emerg Med J 29:1001–1003

    Article  PubMed  Google Scholar 

  26. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD (2012) Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Katus HA. Lindahl B. Morrow DA. Clemmensen PM. Johanson P. Hod H. Underwood R. Bax JJ. Bonow RO. Pinto F. Gibbons RJ. Fox KA. Atar D. Newby LK. Galvani M. Hamm CW. Uretsky BF. Steg PG. Wijns W. Bassand JP. Menasche P. Ravkilde J. Ohman EM. Antman EM. Wallentin LC. Armstrong PW. Simoons ML. Januzzi JL. Nieminen MS. Gheorghiade M. Filippatos G. Luepker RV. Fortmann SP. Rosamond WD. Levy D. Wood D. Smith SC. Hu D. Lopez-Sendon JL. Robertson RM. Weaver D. Tendera M. Bove AA. Parkhomenko AN. Vasilieva EJ. Mendis S. Third universal definition of myocardial infarction. Circulation 126:2020–2035

    Article  PubMed  Google Scholar 

  27. Sun BC, Thiruganasambandamoorthy V, Cruz JD (2012) Consortium to Standardize ED Syncope Risk Stratification, Reporting. Standardized reporting guidelines for emergency department syncope risk-stratification research. Acad Emerg Med 19:694–702

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

We gratefully acknowledge the members of our research team Soo-Min Kim, Catherine Clement RN and Angela Marcantonio for their help, and Dr. Ronald Booth for his help with the interpretation of troponin assays. We also acknowledge the authors of included studies (Drs. Hing, Grossman, Sun, Pfister and Lindner) for their clarifications and assistance in data extraction. This study was funded by a grant from the Department of Emergency Medicine, University of Ottawa. Dr. Thiruganasambandamoorthy was supported by Heart and Stroke Foundation of Canada through the Jump Start Resuscitation Scholarship.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Venkatesh Thiruganasambandamoorthy.

Ethics declarations

Conflict of interest

Dr. Matthew J. Reed is funded by NHS Research Scotland Career Research Fellowship in the UK.

Statement of human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

None.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 25 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Thiruganasambandamoorthy, V., Ramaekers, R., Rahman, M.O. et al. Prognostic value of cardiac biomarkers in the risk stratification of syncope: a systematic review. Intern Emerg Med 10, 1003–1014 (2015). https://doi.org/10.1007/s11739-015-1318-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11739-015-1318-1

Keywords

Navigation