San Francisco Syncope Rule

The San Francisco Syncope Rule (SFSR) is a rule for evaluating the risk of adverse outcomes in patients presenting with fainting or syncope.

The mnemonic for features of the rule is CHESS:

• C - History of congestive heart failure

• H - Hematocrit < 30%

• E - Abnormal ECG

• S - Shortness of breath

• S - Triage systolic blood pressure < 90

A patient with any of the above measures is considered at high risk for a serious outcome such as death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return Emergency Department visit and hospitalization for a related event.

SFSR was retrospectively found to have 98% sensitivity and specificity of 56% for serious causes of syncope.[1] However, external prospective validation of the criteria found sensitivity to be 74%, substantially lower than the initial study.[2] This means that in patients with none of the above criteria, potentially serious causes of syncope were missed in over a quarter of patients. Syncope accounts for 1-2% emergency department visits. Half are hospitalized and of these, 50% have unclear diagnosis and 85% will be simply monitored.

References
  1. Quinn J; McDermott D; Stiell I; Kohn M; Wells G (May 2006). "Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes". Ann Emerg Med. 47 (5): 448–54. doi:10.1016/j.annemergmed.2005.11.019. PMID 16631985.
  2. Birnbaum A; Esses D; Bijur P; Wollowitz A; Gallagher EJ (February 2008). "Failure to Validate the San Francisco Syncope Rule in an Independent Emergency Department Population". Ann Emerg Med. 52 (2): 151–9. doi:10.1016/j.annemergmed.2007.12.007. PMID 18282636.
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