Risk-stratification in the syncope unit.
| Category | Risk Level | Feature | Total per item | Total per group |
|---|---|---|---|---|
| Syncopal event | Low-risk | Associated with prodrome typical of reflex syncope (e.g. light-headedness, feeling of warmth, sweating, nausea, vomiting) | 27 | 76 |
| Low-risk | After sudden unexpected unpleasant sight, sound, smell, or pain | 7 | ||
| Low-risk | After prolonged standing or crowded, hot places | 11 | ||
| Low-risk | During a meal or postprandial | 3 | ||
| Low-risk | Triggered by cough, defaecation, or micturition | 8 | ||
| Low-risk | With head rotation or pressure on carotid sinus (e.g. tumour, shaving, tight collars) | 1 | ||
| Low-risk | Standing from supine/sitting position | 19 | ||
| High-risk (Minor) | No warning symptoms or short (< 10 seconds) prodrome | 31 | 48 | |
| High-risk (Minor) | Family history of Sudden Cardiac Death at young age | 6 | ||
| High-risk (Minor) | Syncope in the sitting position | 11 | ||
| High-risk (Major) | New onset of chest discomfort, breathlessness, abdominal pain, or headache | 1 | 14 | |
| High-risk (Major) | Syncope during exertion or when supine | 11 | ||
| High-risk (Major) | Sudden onset palpitation immediately followed by syncope | 2 | ||
| Past medical history | Low-risk | Long history (years) of recurrent syncope with low-risk features with the same characteristics of the current episode | 14 | 60 |
| Low-risk | Absence of structural heart disease | 46 | ||
| High-risk (Major) | Severe structural or coronary artery disease (heart failure, low Left Ventricular Ejection Fraction or previous myocardial infarction) | 6 | 6 | |
| Physical examination | Low-risk | Normal examination | 45 | 45 |
| High-risk (Major) | Unexplained systolic blood pressure in the emergency department < 90 mmHg | 0 | 10 | |
| High-risk (Major) | Suggestion of gastrointestinal bleed on rectal examination | 0 | ||
| High-risk (Major) | Persistent bradycardia (< 40 b.p.m.) in awake state and in absence of physical training | 0 | ||
| High-risk (Major) | Undiagnosed systolic murmur | 10 | ||
| Electrocardiogram | Low-risk | Normal electrocardiogram | 43 | 43 |
| High-risk (Minor) | Mobitz I second-degree Atrioventricular block block and 1°degree Atrioventricular block with markedly prolonged PR interval | 0 | 3 | |
| High-risk (Minor) | Asymptomatic inappropriate mild sinus bradycardia (40–50 b.p.m.), or slow atrial fibrillation (40–50 b.p.m.) | 1 | ||
| High-risk (Minor) | Paroxysmal Supraventricular Tachycardia or Atrial Fibrillation | 1 | ||
| High-risk (Minor) | Pre-excited QRS complex | 0 | ||
| High-risk (Minor) | Short QTc interval (≤ 340 ms) | 0 | ||
| High-risk (Minor) | Atypical Brugada patterns | 1 | ||
| High-risk (Minor) | Negative T waves in right precordial leads, epsilon waves suggestive of arrhythmogenic right ventricular cardiomyopathy | 0 | ||
| High-risk (Major) | Electrocardiogram changes consistent with acute ischaemia | 0 | 10 | |
| High-risk (Major) | Mobitz II second- and third-degree Atrioventricular block | 0 | ||
| High-risk (Major) | Slow Atrial Fibrillation (< 40 b.p.m.) | 0 | ||
| High-risk (Major) | Persistent sinus bradycardia (< 40 b.p.m.), or repetitive sinoatrial block or sinus pauses >3 seconds in awake state and in absence of physical training | 0 | ||
| High-risk (Major) | Bundle branch block, intraventricular conduction disturbance, ventricular hypertrophy, or Q waves consistent with ischaemic heart disease or cardiomyopathy | 10 | ||
| High-risk (Major) | Sustained and non-sustained ventricular tachycardia | 0 | ||
| High-risk (Major) | Dysfunction of an implantable cardiac device (pacemaker or Implantable Cardioverter-Defibrillator) | 0 | ||
| High-risk (Major) | Type I Brugada pattern | 0 | ||
| High-risk (Major) | ST-segment elevation with type I morphology in leads V1–V3 (Brugada pattern) | 0 | ||
| High-risk (Major) | QTc > 460 ms in repeated 12-lead electrocardiogram indicating LQTS | 0 |
Guideline-based risk-stratification features per category (syncopal event, medical history, physical examination, and electrocardiogram). Totals are shown per feature and summed per risk-group. High-risk (minor) features were interpreted according to the conditional ESC criteria. Minor high-risk features related to the syncopal event were considered high-risk only when associated with structural heart disease and/or an abnormal electrocardiogram. Minor high-risk electrocardiographic features were considered high-risk only when the clinical history was consistent with arrhythmic syncope. Adapted with permission from [1]. © The European Society of Cardiology 2018.