Original Contributions
Applying the Boston Syncope Criteria to Near Syncope

This work was presented at the Society for Academic Emergency Medicine National Meeting, Phoenix, AZ, June 2010; and the Society for Academic Emergency Medicine New England Regional Meeting; Shrewsbury, MA, April 2010.
https://doi.org/10.1016/j.jemermed.2012.01.043Get rights and content

Abstract

Background

We recently demonstrated that near-syncope patients are as likely as syncope patients to experience adverse outcomes. The Boston Syncope Criteria (BSC) identify patients with syncope unlikely to have adverse outcomes and reduce hospitalizations. It is unclear whether these guidelines could reduce hospitalization in near syncope as well.

Objective

To determine if BSC accurately predict which near-syncope patients require hospitalization.

Methods

A prospective observational study enrolled from August 2007 to October 2008 consecutive emergency department (ED) patients (aged > 18 years) with near syncope. BSC were first employed assuming that any patient with risk factors for adverse outcomes should be admitted, and then utilized using a modified rule: if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, patients may be discharged even with risk factors. Outcomes were identified by chart review and 30-day follow-up calls.

Results

Of 244 patients with near syncope, 111 were admitted, with 49 adverse outcomes. No adverse outcomes occurred among discharged patients. If BSC had been followed strictly, another 41 patients with risk factors would have been admitted and 34 discharged, a 3% increase in admission rate. However, using the modified criteria, only 68 patients would have required admission, a 38% reduction in admission, with no missed adverse outcomes on follow-up.

Conclusion

Although near-syncope patients may have risk factors for adverse outcomes similar to those with syncope, if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, these patients may be discharged even with risk factors.

Introduction

Although the literature describing syncope is extensive, minimal data are available regarding the management of near syncope. Near syncope is often excluded from syncope studies or excluded due to difficulty in characterizing near syncope as well as a lack of uniform terminology 1, 2, 3. Other studies, in contrast, have not differentiated between syncope and near syncope 4, 5, 6, 7. It has been postulated that near syncope is associated with fewer comorbidities and perhaps should be considered less ominous (1). However, we have recently demonstrated that if a uniform definition of near syncope is used, patients with near syncope are as likely as patients with syncope to experience adverse outcomes (1).

Syncope accounts for approximately 1–3% of emergency department (ED) visits and up to 6% of all hospital admissions across the United States 8, 9. Hospitalization for syncope has been estimated at $5300 per stay for a total cost of over $2 billion per year nationally 8, 9, 10, 11, 12, 13, 14. As near syncope is often excluded or bundled together with syncope data, the true incidence and cost per hospitalization of near syncope is difficult to know and can only be estimated based on the outcome of syncope patients. In an environment of soaring health care costs and dwindling resources, the need for evidence-based criteria for hospitalization decision-making has become increasingly important (11). The Boston Syncope Criteria and modified Boston Syncope Criteria were designed to identify patients with syncope unlikely to have adverse outcomes and reduce hospital admission 2, 15. These criteria, as part of a clinical pathway, were able to effectively reduce hospital admissions without adverse events 2, 15. It is unclear whether these guidelines could reduce hospital admission of patients with near syncope. Given that patients with near syncope are as likely as patients with syncope to experience adverse outcomes, the objective of this study was to determine whether predefined decision criteria to reduce admission could accurately predict which patients with near syncope require hospitalization.

Section snippets

Study Design

We conducted a prospective, observational, cohort study of consecutive patients presenting with near syncope between November 2007 and August 2008. This design was similar to the design used when studying the syncope cohort (2). Institutional review board approval was received before initiation of the study, with waiver of informed consent.

Study Setting and Population

All patients presenting consecutively to the ED of a large urban teaching hospital with an annual ED census of 55,000 visits were eligible for enrollment.

Results

From October 2007 until August 2008, 1870 patients were screened for a complaint of near syncope. Two hundred forty-four patients met the study definition of near syncope; 61% were female; the average age was 56 years, SD ± 21.

There were a total of 111 admissions with 49 adverse outcomes or critical interventions. Nine of theses patients were admitted to the ED observation unit; none of these patients had adverse outcomes. Furthermore, no adverse outcomes were found in patients discharged home

Discussion

Based on our data, near-syncope patients seem safe for discharge utilizing the Boston Syncope Criteria. However, in our study we also found that near-syncope patients were less likely to be admitted than syncope patients. Therefore if Boston Syncope Criteria were followed strictly, admission rates would have been the same or slightly higher.

Previously, we found that ED patients with near syncope are as likely as patients with syncope to experience adverse outcomes and clinical interventions (1)

Conclusions

Near-syncope patients may potentially be safely discharged utilizing the Boston Syncope criteria. Although near-syncope patients may have risk factors for adverse outcomes similar to those with syncope, if the etiology of near syncope is clearly dehydration or vasovagal, and the ED work-up is otherwise normal, then these patients, like syncope patients, might be discharged even with risk factors for adverse outcome. A prospective validation study applying the modified Boston Syncope Criteria to

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