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Emergency care
Age is the most important clinical feature to help rule out cardiac syncope
  1. Jack O'Sullivan1,2
  1. 1 Division of Cardiology, Department of Medicine, Stanford University, Palo Alto, California, USA
  2. 2 Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
  1. Correspondence to Dr Jack O'Sullivan, Division of Cardiology, Department of Medicine, Stanford University, Palo Alto, CA 94305-6104, USA; jackos{at}

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A 2019 systematic review of diagnostic accuracy studies has shown that age greater than 35 has the highest sensitivity for cardiac causes in patients with syncope.

Syncope accounts for more than 1.2 million emergency department presentations annually in the USA.1 Eliciting the underlying cause of syncope is challenging: the differential diagnosis is broad, numerous diagnostic tests are poorly sensitive, and the aetiology includes both benign and sinister causes. Particularly important diagnoses to consider are cardiac causes of syncope including arrhythmia, structural heart disease, or pulmonary embolism,.2

To aid clinicians, the American College of Cardiology and American Heart Association have outlined an approach to evaluate syncopal patients in their 2017 guideline.3 Due to the low diagnostic yield of laboratory testing, and advanced cardiac and neurological imaging, this guideline only recommends a history, physical examination, and a 12-lead ECG as a routine part of a syncope work up.3 Also of note is this guideline’s ambivalence to structured risk scores: “published risk scores don’t perform better than unstructured clinical judgement”.1 3 …

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  • Contributors JO'S is the sole author.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.