Syncope Emergency Workup: San Francisco Rule

Emergency department evaluation of syncope focuses on two questions: (1) Is there a dangerous underlying cause (cardiac syncope)? (2) Can the patient be safely discharged or does admission required? Several validated risk stratification tools assist: The San Francisco Syncope Rule (SFSR) uses the mnemonic CHESS: Congestive heart failure history, Hematocrit <30%, ECG abnormality (new or non-sinus rhythm), Shortness of breath, and Systolic BP <90 at any time. Any single positive criterion identifies patients at risk for serious outcomes within 30 days (sensitivity ~96%, specificity ~62%). The Canadian Syncope Risk Score (CSRS) provides more granular risk stratification using clinical, ECG, and ED variables: heart disease history, elevated troponin, abnormal QRS axis, QTc >480 ms, ED diagnosis of vasovagal syncope (protective, subtracts from score), and ED diagnosis of cardiac syncope. The EGSYS score (Evaluation of Guidelines in SYncope Study) differentiates cardiac from non-cardiac syncope: palpitations before syncope (+4), abnormal ECG or heart disease (+3), syncope during effort (+3), syncope while supine (+2), preceded by autonomic prodromes (nausea, warmth — minus 1), preceded by predisposing/precipitating factors (minus 1). Score ≥3 suggests cardiac etiology....