The Case

A 62-year-old female with a history of anemia and hypertension presents following an episode of syncope that morning while making her coffee. She felt light-headed. As she reached for the wall, the room “went dark.” The next thing she remembers is waking up on the floor. She denies headache, chest pain, shortness of breath, or palpitations. She has been feeling well recently and eating and drinking

as usual. She has been taking her antihypertensives as prescribed. She is now back to her neurological baseline but feels fatigued.

In the emergency department, she appears tired but well. Her vital signs and physical exam are unremarkable. She has no signs of head trauma, no cardiac murmurs, and no signs of heart failure. Her initial ECG is normal. Bloodwork has been sent to the lab. What is the utility of cardiac biomarkers in this patient? What will her ultimate ED disposition be if her workup is unremarkable?

The Tricky Problem of Syncope

In many ways, syncope management is a microcosm of emergency medicine. The differential diagnosis is broad, and the etiology is typically benign but rarely can also be serious or life-threatening. Safe medical decision-making requires a mixture of diagnostic acumen and risk stratification. Which patients can be safely discharged from the emergency department? Which require a stay in the observation unit or hospital? This question has vexed emergency clinicians for years.

Over the last 20 years, researchers have attempted to identify risk factors for adverse events after syncope. The usual suspects emerged: advanced age, history of heart disease, abnormal vital signs, abnormal ECG.

More recently, researchers have attempted to create simple, objective risk scores to help clinicians deliver sensible care to syncope patients—care that matches their risk profile.

The San Francisco Syncope Rule gained early acceptance but has gradually faded away after attempts to validate the score were unsuccessful.

Developing a New Metric

We wanted to know if we could improve clinical outcomes and reduce low-yield admissions by developing a more accurate and reliable syncope risk score. So with funding from the National Institutes of Health, we conducted a five-year multicenter study to enroll a large enough sample size. We included patients ages 60 years and older with an ED complaint of syncope or near syncope. We excluded patients with other causes of loss of consciousness (eg, concussion, hypoglycemia, seizure) and those with a serious diagnosis identified in the emergency department (eg, myocardial infarction, pulmonary embolism, gastrointestinal bleed).

After six years of hard work, and with the help of about a dozen collaborators, our syncope risk score, the aptly named “FAINT Score, was finally published in the Annals of Emergency Medicine.”1 In the end, we had enrolled more than 3,100 older adults with unexplained syncope or near syncope across 11 emergency departments in the United States. The primary outcome was death or serious cardiac event at 30 days.

The FAINT Score consists of five variables (see Table 1). A FAINT Score of zero had a sensitivity of over 96 percent and specificity of 22 percent for predicting death or serious cardiac event at 30 days (see Table 1).