• Ramon T Saccilotto, Christian H Nickel, Heiner C Bucher, Ewout W Steyerberg, Roland Bingisser, and Michael T Koller.
• Basel Institute for Clinical Epidemiology and Biostatistics, Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland. saccilottor@uhbs.ch
• CMAJ. 2011 Oct 18; 183 (15): E1116E1126E1116-26.

BackgroundThe San Francisco Syncope Rule has been proposed as a clinical decision rule for risk stratification of patients presenting to the emergency department with syncope. It has been validated across various populations and settings. We undertook a systematic review of its accuracy in predicting short-term serious outcomes.MethodsWe identified studies by means of systematic searches in seven electronic databases from inception to January 2011. We extracted study data in duplicate and used a bivariate random-effects model to assess the predictive accuracy and test characteristics.ResultsWe included 12 studies with a total of 5316 patients, of whom 596 (11%) experienced a serious outcome. The prevalence of serious outcomes across the studies varied between 5% and 26%. The pooled estimate of sensitivity of the San Francisco Syncope Rule was 0.87 (95% confidence interval [CI] 0.79-0.93), and the pooled estimate of specificity was 0.52 (95% CI 0.43-0.62). There was substantial between-study heterogeneity (resulting in a 95% prediction interval for sensitivity of 0.55-0.98). The probability of a serious outcome given a negative score with the San Francisco Syncope Rule was 5% or lower, and the probability was 2% or lower when the rule was applied only to patients for whom no cause of syncope was identified after initial evaluation in the emergency department. The most common cause of false-negative classification for a serious outcome was cardiac arrhythmia.InterpretationThe San Francisco Syncope Rule should be applied only for patients in whom no cause of syncope is evident after initial evaluation in the emergency department. Consideration of all available electrocardiograms, as well as arrhythmia monitoring, should be included in application of the San Francisco Syncope Rule. Between-study heterogeneity was likely due to inconsistent classification of arrhythmia.

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