Did This Patient Have Cardiac Syncope?: The Rational Clinical Examination Systematic Review

• Published in: JAMA : the journal of the American Medical Association 2019-06, Vol.321 (24), p.2448-2457
• Main Authors: Albassam, Omar T, Redelmeier, Robert J, Shadowitz, Steven, Husain, Aatif M, Simel, David, Etchells, Edward E
• Format: Article
• Language: English
• Subjects: Accuracy; Age Factors; Aged; Biomarkers; Biomarkers - analysis; Cardiac output; Cardiovascular disease; Cardiovascular diseases; Coronary artery disease; Cyanosis; Diagnosis, Differential; Diagnostic systems; EKG; Electrocardiography; Emergency medical services; Female; Fibrillation; Flutter; Headache; Health care; Heart diseases; Heart Diseases - complications; Heart Diseases - diagnosis; Humans; Hypotension; Mood; Quality assessment; Risk Factors; Sensitivity; Sensitivity and Specificity; Signs and symptoms; Syncope; Syncope - etiology; Systematic review; Vasovagal syncope
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2019.8001

IMPORTANCE: Syncope can result from a reduction in cardiac output from serious cardiac conditions, such as arrhythmias or structural heart disease (cardiac syncope), or other causes, such as vasovagal syncope or orthostatic hypotension. OBJECTIVE: To perform a systematic review of studies of the accuracy of the clinical examination for identifying patients with cardiac syncope. STUDY SELECTION: Studies of adults presenting to primary care, emergency departments, or referred to specialty clinics. DATA EXTRACTION AND SYNTHESIS: Relevant data were abstracted from articles in databases through April 9, 2019, and methodologic quality was assessed. Included studies had an independent comparison to a reference standard. MAIN OUTCOMES AND MEASURES: Sensitivity, specificity, and likelihood ratios (LRs). RESULTS: Eleven studies of cardiac syncope (N = 4317) were included. Age at first syncope of at least 35 years was associated with greater likelihood of cardiac syncope (n = 323; sensitivity, 91% [95% CI, 85%-97%]; specificity, 72% [95% CI, 66%-78%]; LR, 3.3 [95% CI, 2.6-4.1]), while age younger than 35 years was associated with a lower likelihood (LR, 0.13 [95% CI, 0.06-0.25]). A history of atrial fibrillation or flutter (n = 323; sensitivity, 13% [95% CI, 6%-20%]; specificity, 98% [95% CI, 96%-100%]; LR, 7.3 [95% CI, 2.4-22]), or known severe structural heart disease (n = 222; range of sensitivity, 35%-51%, range of specificity, 84%-93%; range of LR, 3.3-4.8; 2 studies) were associated with greater likelihood of cardiac syncope. Symptoms prior to syncope that were associated with lower likelihood of cardiac syncope were mood change or prodromal preoccupation with details (n = 323; sensitivity, 2% [95% CI, 0%-5%]; specificity, 76% [95% CI, 71%-81%]; LR, 0.09 [95% CI, 0.02-0.38]), feeling cold (n = 412; sensitivity, 2% [95% CI, 0%-5%]; specificity, 89% [95% CI, 85%-93%]; LR, 0.16 [95% CI, 0.06-0.64]), or headache (n = 323; sensitivity, 3% [95% CI, 0%-7%]; specificity, 80% [95% CI, 75%-85%]; LR, 0.17 [95% CI, 0.06-0.55]). Cyanosis witnessed during the episode was associated with higher likelihood of cardiac syncope (n = 323; sensitivity, 8% [95% CI, 2%-14%]; specificity, 99% [95% CI, 98%-100%]; LR, 6.2 [95% CI, 1.6-24]). Mood changes after syncope (n = 323; sensitivity, 3% [95% CI, 0%-7%]; specificity, 83% [95% CI, 78%-88%]; LR, 0.21 [95% CI, 0.06-0.65]) and inability to remember behavior prior to syncope (n = 323; sensitivity, 5% [95% CI, 0%-9%]; specificity, 82% [9