Comparison of the San Francisco Syncope Rule, Canadian Syncope Risk Score and Anatolian Syncope Rule in Patients Presenting to the Emergency Department with Syncope

Burcu Doğan; Seval Komut; Hasan Sultanoğlu; Cemal Yasin Duran; Merve Yazla; Rabia Handan Günsay

doi:10.18621/eurj.1802723

Comparison of the San Francisco Syncope Rule, Canadian Syncope Risk Score and Anatolian Syncope Rule in Patients Presenting to the Emergency Department with Syncope

Abstract

Objectives: Syncope is a common cause of emergency department admissions and poses challenges in patient management due to its broad etiology and risk of short-term adverse events. This study aimed to comparatively evaluate the ability of the San Francisco Syncope Rule, Canadian Syncope Risk Score and Anatolian Syncope Rule to predict short-term (1-week and 1-month) adverse events in patients presenting to the emergency department with syncope.

Methods: This multicenter, prospective, observational study included 108 patients who presented to the emergency departments of two tertiary-level hospitals with syncope. Patients aged <18 years, pregnant women, those with non-syncopal causes of transient loss of consciousness, and those requiring hospitalization at presentation were excluded. Patients were contacted by phone on the 7th and 30th days after discharge to assess adverse events, including death, life-threatening arrhythmias, myocardial infarction, aortic dissection, pulmonary embolism, major bleeding, and subarachnoid hemorrhage.

Results: The mean age was 45.9±18.9 years, and 57.4% were female. The most common comorbidity was hypertension (34.3%), and vasovagal syncope (47.2%) was the leading etiology. Within 1 week, 8 (7.4%) patients experienced adverse events; none occurred at 1 month. Median scores were 0 for the San Francisco Syncope Rule, 1 for the Anatolian Syncope Rule, and 0 for the Canadian Syncope Risk Score; among those with events: 0.5, 2, 3, respectively.

Conclusions: The San Francisco Syncope Rule showed limited early discrimination, the Canadian Syncope Risk Score identified high-risk patients, and the Anatolian Syncope Rule better stratified low–moderate risk groups. Risk scores should complement, not replace, clinical judgment.

Keywords

Ethical Statement

This study was approved by the Hitit University Non-Interventional Clinical Research Ethics Committee (Decision No: 2023-03; date: 29.03.2023). All procedures were conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all individual participants included in the study.

References

1. Albassam OT, Redelmeier RJ, Shadowitz S, Husain AM, Simel D, Etchells EE. Did This Patient Have Cardiac Syncope?: The Rational Clinical Examination Systematic Review. JAMA. 2019;321(24):2448-2457. doi: 10.1001/jama.2019.8001.
2. Furlan L, Jacobitti Esposito G, Gianni F, Solbiati M, Mancusi C, Costantino G. Syncope in the Emergency Department: A Practical Approach. J Clin Med. 2024;13(11):3231. doi: 10.3390/jcm13113231.
3. Bozorgi A, Hosseini K, Jalali A, Tajdini M. A New Feasible Syncope Risk Score Appropriate for Emergency Department: A Prospective Cohort Study. Crit Pathw Cardiol. 2018;17(3):151-154. doi: 10.1097/HPC.0000000000000146.
4. Rivasi G, Ungar A, Moya A, Brignole M, Sutton R, Fedorowski A. Syncope: new solutions for an old problem. Kardiol Pol. 2021;79(10):1068-1078. doi: 10.33963/KP.a2021.0138.
5. Tannenbaum L, Keim SM, April MD, Long B, Koyfman A, Mattu A. Can I Send This Syncope Patient Home From the Emergency Department? J Emerg Med. 2021;61(6):801-809. doi: 10.1016/j.jemermed.2021.07.060.
6. Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004;43(2):224-232. doi: 10.1016/s0196-0644(03)00823-0. PMID: 14747812.
7. Kayayurt K, Akoglu H, Limon O, et al. Comparison of existing syncope rules and newly proposed Anatolian syncope rule to predict short-term serious outcomes after syncope in the Turkish population. Int J Emerg Med. 2012;5:17. doi: 10.1186/1865-1380-5-17.
8. Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016;188(12):E289-E298. doi: 10.1503/cmaj.151469.

9. Bernier R, Tran DT, Sheldon RS, Kaul P, Sandhu RK. A Population-Based Study Evaluating Sex Differences in Patients Presenting to Emergency Departments With Syncope. JACC Clin Electrophysiol. 2020;6(3):341-347. doi: 10.1016/j.jacep.2019.11.002.
10. Ling L, Feng T, Xue X, Ling Z. Etiology, risk factors, and prognosis of patients with syncope: A single-center analysis. Ann Noninvasive Electrocardiol. 2021;26(6):e12891. doi: 10.1111/anec.12891.
11. Wakai A, Sinert R, Zehtabchi S, et al. Risk-stratification tools for emergency department patients with syncope: A systematic review and meta-analysis of direct evidence for SAEM GRACE. Acad Emerg Med. 2025;32(1):72-86. doi: 10.1111/acem.15041.
12. Gibson TA, Weiss RE, Sun BC. Predictors of Short-Term Outcomes after Syncope: A Systematic Review and Meta-Analysis. West J Emerg Med. 2018;19(3):517-523. doi: 10.5811/westjem.2018.2.37100.
13. Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006;47(5):448-454. doi: 10.1016/j.annemergmed.2005.11.019.
14. Safari S, Baratloo A, Hashemi B, et al. Comparison of different risk stratification systems in predicting short-term serious outcome of syncope patients. J Res Med Sci. 2016;21:57. doi: 10.4103/1735-1995.187305.
15. Moussa BS, Ali MA, Ali AAE, Abou Zeid AESM. Assessment of Canadian Syncope Risk Score in the prediction of outcomes of patients with syncope at the Emergency Department of Suez Canal University: STROBE compliant. Medicine (Baltimore). 2022;101(25):e29287. doi: 10.1097/MD.0000000000029287.
16. Liang Y, Li X, Tse G, et al. Syncope Prediction Scores in the Emergency Department. Curr Cardiol Rev. 2022;18(5):1-7. doi: 10.2174/1573403X18666220321104129.
17. Brignole M, Moya A, de Lange FJ, et al; ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883-1948. doi: 10.1093/eurheartj/ehy037.

Details

Primary Language

English

Subjects

Health Services and Systems (Other)

Journal Section

Research Article

Authors

Burcu Doğan ^*
0000-0003-1379-7832
Türkiye

Seval Komut
0000-0002-9558-4832
Türkiye

Hasan Sultanoğlu
0000-0003-4099-572X
Türkiye

Cemal Yasin Duran
0009-0001-7978-7365
Türkiye

Merve Yazla
0000-0002-4092-4633
Türkiye

Rabia Handan Günsay
0000-0003-1176-0307
Türkiye

Early Pub Date

December 5, 2025

Publication Date

January 4, 2026

Submission Date

October 13, 2025

Acceptance Date

November 20, 2025

Published in Issue

Year 2026 Volume: 12 Number: 1

DOI

https://doi.org/10.18621/eurj.1802723

IZ

https://izlik.org/JA69HH46RH

Cite

RIS / Bibtex

AMA

1.Doğan B, Komut S, Sultanoğlu H, Duran CY, Yazla M, Günsay RH. Comparison of the San Francisco Syncope Rule, Canadian Syncope Risk Score and Anatolian Syncope Rule in Patients Presenting to the Emergency Department with Syncope. Eur Res J. 2026;12(1):108-118. doi:10.18621/eurj.1802723