This is the current release of the guideline.

This guideline updates a previous version: American College of Emergency Physicians (ACEP). Clinical policy: critical issues in the evaluation and management of patients presenting with syncope. Ann Emerg Med 2001 Jun;37(6):771-6.

Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are repeated at the end of the Major Recommendations.

1. What history and physical examination data help to risk-stratify patients with syncope?

   Level A recommendations. Use history or physical examination findings consistent with heart failure to help identify patients at higher risk of an adverse outcome.

   Level B recommendations.

   1. Consider older age, structural heart disease, or a history of coronary artery disease as risk factors for adverse outcome.
   2. Consider younger patients with syncope that is nonexertional, without history or signs of cardiovascular disease, a family history of sudden death, and without comorbidities to be at low risk of adverse events.

   Level C recommendations. None specified

2. What diagnostic testing data help to risk-stratify patients with syncope?

   Level A recommendations. Obtain a standard 12-lead electrocardiogram (ECG) in patients with syncope.

   Level B recommendations. None specified.

   Level C recommendations. Laboratory testing and advanced investigative testing such as echocardiography or cranial computed tomography (CT) scanning need not be routinely performed unless guided by specific findings in the history or physical examination.

3. Who should be admitted after an episode of syncope of unclear cause?

   Level A recommendations. None specified.

   Level B recommendations.

   1. Admit patients with syncope and evidence of heart failure or structural heart disease.
   2. Admit patients with syncope and other factors that lead to stratification as high-risk for adverse outcome:

      Factors that lead to stratification as high-risk for adverse outcomes:

      • Older age and associated comorbidities (Different studies use different ages as threshold for decisionmaking. Age is likely a continuous variable that reflects the cardiovascular health of the individual rather than an arbitrary value.)
      • Abnormal ECG (ECG abnormalities, including acute ischemia, dysrhythmias, or significant conduction abnormalities.)
      • Hematocrit (Hct) <30 (if obtained)
      • History or presence of heart failure, coronary artery disease, or structural heart disease

   Level C recommendations. None specified.

Definitions:

Strength of Evidence

Literature Classification Schema^

^ Some designs (e.g., surveys) will not fit this schema and should be assessed individually.

*Objective is to measure therapeutic efficacy comparing >2 interventions.

**Objective is to determine the sensitivity and specificity of diagnostic tests.

*** Objective is to predict outcome including mortality and morbidity.

Approach to Downgrading Strength of Evidence*

*See "Description of Methods Used to Analyze the Evidence" field for more information.

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues)

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies)

Level C recommendations. Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2001 (revised 2007 Apr)

American College of Emergency Physicians - Medical Specialty Society

Supported by the Emergency Nurses Association, February 21, 2007.

American College of Emergency Physicians

American College of Emergency Physicians (ACEP) Clinical Policies Subcommittee on Syncope

ACEP Clinical Policies Committee

Clinical Policies Subcommittee on Syncope: J. Stephen Huff, MD (Subcommittee Chair); Wyatt W. Decker, MD; James V. Quinn, MD, MS; Andrew D. Perron, MD; Anthony M. Napoli, MD (EMRA Representative 2004-2006); Suzanne Peeters, MD (Dutch Society of Emergency Physicians); Andy S. Jagoda, MD

American College of Emergency Physicians (ACEP) Clinical Policies Committee (Oversight Committee) Members: Andy S. Jagoda, MD (Chair 2003-2006; Co-Chair 2006-2007); Wyatt W. Decker, MD (Co-Chair 2006-2007); Deborah B. Diercks, MD; Jonathan A. Edlow, MD; Francis M. Fesmire, MD; Steven A. Godwin, MD; Sigrid A. Hahn, MD; John M. Howell, MD; J. Stephen Huff, MD; Thomas W. Lukens, MD, PhD; Donna L. Mason, RN, MS, CEN (ENA Representative 2004-2006); Anthony M. Napoli, MD (EMRA Representative 2004-2006); Devorah Nazarian, MD; Jim Richmann, RN, BS, MA(c), CEN (ENA Representative 2006-2007); Scott M. Silvers, MD; Edward P. Sloan, MD, MPH; Robert L. Wears, MD, MS (Methodologist); Molly E. W. Thiessen, MD (EMRA Representative 2007); Stephen J. Wolf, MD; Cherri D. Hobgood, MD (Board Liaison 2004-2006); Rhonda R. Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American College of Emergency Physicians (ACEP). Clinical policy: critical issues in the evaluation and management of patients presenting with syncope. Ann Emerg Med 2001 Jun;37(6):771-6.

None available

None available

This NGC summary was completed by ECRI on January 29, 2003. The information was verified by the guideline developer on March 13, 2003. This NGC summary was updated by ECRI Institute on April 23, 2007. The updated information was verified by the guideline developer on April 24, 2007.