If a cause of syncope can be determined on ED evaluation, identification of high-risk patients is simple. Those patients with acute neurologic deficits or life-threatening disorders are at immediate risk of morbidity. Additionally, patients with cardiac causes of syncope represent a high-risk group for major morbidity or death. On evaluation in the emergency department, however, a cause of syncope is not identifiable in up to half of patients. 3 Efforts must then be focused to identify those patients at high risk for a cardiac cause of syncope. A recent prospective study focused on risk stratification based on clinical and electrocardiographic characteristics.17 The study found four significant predictors of sudden cardiac death or significant dysrhythmia within one year of a syncopal event: abnormal electrocardiogram (anything other than nonspecific ST-T changes), age greater than 45 years, history of ventricular dysrhythmia, and history of congestive heart failure. The risk went up with increased numbers of these predictors. This supports prior studies that show that the prognosis of syncope in patients without heart disease is very good.18!9 The young patient with syncope, a normal physical examination, and a normal electrocardiogram has a very low risk of morbidity. Additionally, patients who have recurrent syncope with more than five episodes in 1 year are more likely to have vasovagal syncope or a psychiatric diagnosis than dysrhythmia as the cause.2

Indications for hospital admission, therefore, include patients with acute neurologic or life-threatening disorders and patients at risk for a cardiac etiology of syncope (Fig.. ...46.-1). Patients with more than one episode, who are discharged from the ED should be accompanied by a responsible adult and be advised not to drive, work at heights, or operate machinery until further outpatient evaluation.

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