High- and low-risk factors in syncope patients

Low-risk factors	High-risk factors
Characteristics of the patients
Young age (<40 years)
Characteristics of syncope
Only while standing	During exertion
Standing from supine/sitting position	In supine position
Nausea/vomiting before syncope	New onset chest discomfort
Feeling of warmth before syncope	Palpitations before syncope
Triggered by painful/emotionally distressing stimulus	Associated with dyspnea
Triggered by cough/defecation/micturition
Factors present in the history of the patient
Prolonged history (years) of syncope with same characteristics as current episode	Family history of sudden death
	Decompensated (congestive) heart failure
	Aortic stenosis
	Left ventricular outflow tract disease
	Dilated cardiomyopathy
	Hypertrophic cardiomyopathy
	Arrhythmogenic right ventricular cardiomyopathy
	Left ventricular ejection fraction <35%
	Documented ventricular arrhythmia
	Coronary artery disease/Myocardial infarction
	Congenital heart disease
	Pulmonary hypertension
	ICD implantation
Symptoms, signs, or variables associated with the syncopal episode
	Anemia (Hb <9 g/dL)
	Lowest systolic blood pressure in the emergency department <90 mmHg
	Sinus bradycardia (<40 bpm)
ECG features*
	New (or previously unknown) left bundle branch block
	Bifascicular block + first degree AV block
	Brugada ECG pattern
	ECG changes consistent with acute ischemia
	Non-sinus rhythm (new)
	Bifascicular block
	Prolonged QTc (>450 ms)

According to characteristics of the patient and the syncopal episode, the subject can be defined as low, high or indeterminate risk. Low risk: patients with one or more low-risk characteristics and without any high-risk characteristics. High risk: patients with at least one high-risk characteristic. Intermediate or indeterminate risk: patients without any high- or low-risk characteristics, or patients with only low-risk factors and some co-morbidities such as chronic renal failure, respiratory failure, hepatic failure, neoplasm, cerebrovascular disease or previous history of heart disease. Note that finding any of these abnormalities does not always lead to a definite diagnosis.

ICD: implantable cardioverter defibrillator; AV: atrioventricular; bpm: beats per minute; ECG: electrocardiogram.
* Note that not all the ECG patterns are covered by the table, and some other ECG patterns could be considered in stratifying patient risk such as short QT syndrome, early repolarization, ECG findings indicating hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and incidental finding of Q wave.

Reproduced from: Costantino G, Sun BC, Barbic F, et al. Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department. Eur Heart J 2016; 37(19):1493-8. By permission of Oxford University Press on behalf of the European Society of Cardiology. Copyright © 2016. www.escardio.org.

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High- and low-risk factors in syncope patients