Perspective:

The CSRS is calculated numerically from several variables: predisposition to vasovagal symptoms, heart disease history, systolic blood pressure <90 or >180 mm Hg, elevated troponin, abnormal QRS axis, QRS duration >130 msec, corrected QT interval >480 msec, and whether vasovagal or cardiac syncope was diagnosed in the ED. The current manuscript suggests that CSRS low-risk patients may be discharged from the ED after 2 hours, and most medium- and high-risk patients may be discharged after 6 hours given appropriate workup. The authors argue in favor of a 15-day outpatient monitoring period for medium-risk patients at a selected threshold and all high-risk patients, and for early application of the ambulatory monitor following syncope, when the yield appears the highest. Notably, the outcomes were censored at 30 days. Additionally, the risk score should not be used in patients presenting after 24 hours following syncope, if syncope lasted >5 minutes, resulted in change in mental status, was an obvious witnessed seizure, intoxication, or if head trauma caused loss of consciousness. The applicability of this paradigm has been validated at Canadian tertiary medical centers, and its usefulness in other patient populations is unknown. Additionally, it relies on ED diagnosis of ‘vasovagal syncope’ or ‘cardiac syncope’ based on the treating ED physician’s early clinical impression, which may be subjective. The manuscript does not directly address which medium- and high-risk patients benefit from hospitalization, and additional studies are clearly needed.