Prospective Validation of the Canadian Syncope Risk Score in an Indian Emergency Department: Performance in Syncope and Near-Syncope

Q: What are the key findings of this study?

The Canadian Syncope Risk Score predicted 30-day serious adverse events with an AUC of 0.872 (95% CI 0.822-0.922), stratifying risk from 0% in very-low-risk to 81.8% in very-high-risk patients.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Syncope and near-syncope (n=272). Intervention: Canadian Syncope Risk Score (CSRS) vs. Lower CSRS risk tiers / Near-syncope vs. Syncope. Primary outcome: Composite of 30-day serious adverse events (arrhythmic or non-arrhythmic) not evident during index ED evaluation (AUC 0.872, 95% CI 0.822-0.922, p=<0.001).

Q: What does this research mean for the field?

The Canadian Syncope Risk Score effectively stratifies the risk of 30-day serious adverse events in patients presenting with syncope or near-syncope in an Indian emergency department setting (AUC 0.872). Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To prospectively validate the Canadian Syncope Risk Score (CSRS) in an Indian emergency department cohort and evaluate its performance in patients presenting with near-syncope.

Manan Shah; Sanjay J. Mehta; Sagar Shah; Deepack Kotharthil

doi:10.21203/rs.3.rs-11009014/v1

October 14, 2026Open Access

Prospective Validation of the Canadian Syncope Risk Score in an Indian Emergency Department: Performance in Syncope and Near-Syncope

View Full Paper

Ask AI

Bookmark

Share

Key result

Canadian Syncope Risk Score accurately predicts 30-day serious adverse events with ~0.87 AUC.

AUC 0.872
95% CI 0.822-0.922
P<0.001
n=272

Why the study?

The Canadian Syncope Risk Score was derived and validated in Canadian emergency departments, but it had not been prospectively evaluated in Indian patients or formally assessed in near-syncope presentations.

Does the Canadian Syncope Risk Score accurately stratify 30-day serious adverse events in adults presenting with syncope or near-syncope to an Indian emergency department?

Key Points

To prospectively validate the Canadian Syncope Risk Score (CSRS) in an Indian emergency department cohort and evaluate its performance in patients presenting with near-syncope.
Prospective single-center observational cohort study at a 750-bed quaternary care hospital in Mumbai, India, conducted from January 2023 to March 2024.
Consecutively enrolled 272 adults aged ≥ 18 years (mean age 54.9 ± 19.4 years; 54% male) presenting within 24 hours of syncope (n = 149) or near-syncope (n = 123).
Evaluated the CSRS via ROC curve analysis for the primary outcome of 30-day serious adverse events (arrhythmic or non-arrhythmic) not evident during index emergency assessment.
Overall, 54 of 272 patients (19.9%) experienced 30-day serious adverse outcomes (including 6 deaths), with event rates rising from 0% in very low risk to 81.8% in very high risk tiers (p < 0.001).
For the entire cohort, a CSRS cutoff of 2 yielded an AUC of 0.872 (95% CI, 0.822–0.922), 74.6% sensitivity, and 83.0% specificity, whereas a cutoff of 0 achieved 96.4% sensitivity.
In near-syncope patients, serious adverse events occurred in 10.6% (compared to 27.5% in frank syncope; p = 0.001), with a score cutoff of 1 yielding an AUC of 0.860, 76.9% sensitivity, and 76.4% specificity.

Study Design

Type

Cohort (n=272)

Multicenter

No

Structured PICO

Does the Canadian Syncope Risk Score accurately stratify 30-day serious adverse events in adults presenting with syncope or near-syncope to an Indian emergency department?

P

Population

272 adults (mean age 54.9 years, 46% female) presenting to an Indian emergency department within 24 hours of syncope or near-syncope, free of serious conditions evident during index evaluation, followed for 30 days.

E

Exposure

Risk stratification using the Canadian Syncope Risk Score (CSRS), which incorporates clinical variables, ECG findings, high-sensitivity troponin, and the treating physician's clinical impression of syncope etiology at ED discharge, stratifying patients into five risk categories (very low, low, medium, high, and very high).

O

Outcome

Composite of 30-day serious clinical and procedural adverse events not evident during the index ED evaluation, classified as arrhythmic (clinically significant arrhythmias, pacemaker or defibrillator implantation, cardioversion, or unexplained death) or non-arrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, hemorrhage, or other serious non-arrhythmic diagnoses).composite

Main Result

Effect estimate: AUC 0.872 (95% CI 0.822-0.922)

Absolute Event Rate: 81.8% vs 0%

p-value: p=<0.001

This study provides the first prospective validation of the Canadian Syncope Risk Score in an Indian emergency department, demonstrating strong diagnostic accuracy across both frank syncope and near-syncope presentations and supporting its use to safely reduce unnecessary hospital admissions.

Limitations

Single-center design at a quaternary private hospital limits generalizability to public hospitals, secondary care facilities, and non-metropolitan EDs.
Modest sample size resulted in sparse data in the high and very high-risk subgroups, reducing precision of point estimates.
The CSRS component reflecting physician etiology classification (vasovagal vs. cardiac) is inherently subjective.
High discharge against medical advice (DAMA) rate of 22.4% introduced potential differential loss to follow-up risk.
Findings cannot be extrapolated to pediatric patients or pregnant women, who were excluded.
Single-center design at a quaternary private hospital limits generalizability to public hospitals, secondary care facilities, and non-metropolitan EDs
Small sample size resulted in sparse data in the high and very high-risk subgroups, reducing precision of point estimates in these strata
The CSRS component reflecting physician etiology classification (vasovagal vs. cardiac) is inherently subjective and may vary across providers and training levels
A 22.4% discharge against medical advice (DAMA) rate introduced differential loss to follow-up risk
Findings cannot be extrapolated to pediatric patients or pregnant women, who were excluded per the original CSRS design

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Supports CSRS risk stratification in Indian ED syncope patients; extends Canadian validation to a new population.

Abstract

Background Risk stratification of patients presenting with syncope in the emergency department (ED) remains challenging owing to the absence of universally validated clinical decision tools applicable to non-Western populations. The Canadian Syncope Risk Score (CSRS) was derived and validated in Canadian EDs but has not been prospectively evaluated in Indian patients, nor formally assessed in near-syncope presentations. This study aimed to validate the CSRS in an Indian ED population and extend its evaluation to patients presenting with near-syncope. Methods Prospective single-center observational cohort study conducted at a 750-bed quaternary care hospital in Mumbai, India, from January 2023 to March 2024. Adults aged ≥ 18 years presenting within 24 hours of syncope or near-syncope were enrolled consecutively. The primary outcome was a composite of 30-day serious adverse events not evident during index ED evaluation, classified as arrhythmic (arrhythmias, procedural interventions) or non-arrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage). Diagnostic accuracy of CSRS at different cutoff values was evaluated using ROC curve analysis. Results Of 272 patients analyzed (mean age 54.9 ± 19.4 years; 54% male), 54 (19.9%) experienced 30-day serious outcomes, including 6 deaths. Adverse event rates increased progressively across CSRS risk tiers, from 0% (very low) to 81.8% (very high; p < 0.001). At a cutoff of 2 for the overall cohort, CSRS demonstrated an AUC of 0.872 (95% CI, 0.822–0.922), sensitivity of 74.6%, and specificity of 83.0%. In near-syncope patients, a cutoff of 1 yielded an AUC of 0.860, sensitivity of 76.9%, and specificity of 76.4%. At a cutoff of 0, sensitivity reached 96.4%, supporting its use as a high-sensitivity rule-out strategy. Conclusions The CSRS demonstrated strong ordinal risk discrimination and diagnostic accuracy consistent with prior validation studies in a prospective Indian ED cohort, and performed reliably in near-syncope patients. Implementation of the CSRS has the potential to reduce unnecessary admissions and standardize ED disposition decisions without compromising patient safety. This study provides the first prospective evidence for CSRS applicability across the full syncopal spectrum in a non-Western ED setting.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Shah et al. (2026) conducted a cohort in Syncope and near-syncope (n=272). Canadian Syncope Risk Score (CSRS) vs. Lower CSRS risk tiers / Near-syncope vs. Syncope was evaluated on Composite of 30-day serious adverse events (arrhythmic or non-arrhythmic) not evident during index ED evaluation (AUC 0.872, 95% CI 0.822-0.922, p=<0.001). The Canadian Syncope Risk Score predicted 30-day serious adverse events with an AUC of 0.872 (95% CI 0.822-0.922), stratifying risk from 0% in very-low-risk to 81.8% in very-high-risk patients.

synapsesocial.com/papers/6aee6b6871a7594806220959 https://doi.org/10.21203/rs.3.rs-11009014/v1

View Full Paper

Ask AI

Bookmark

Share

Prospective Validation of the Canadian Syncope Risk Score in an Indian Emergency Department: Performance in Syncope and Near-Syncope

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Prospective Validation of the Canadian Syncope Risk Score in an Indian Emergency Department: Performance in Syncope and Near-Syncope

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading