The San Francisco Syncope Rule (SFSR)
The San Francisco Syncope Rule is a clinical decision tool designed to identify patients presenting with syncope (fainting) or near-syncope who are at high risk for serious short-term adverse outcomes within 30 days.
The rule relies on a memorable 5-item checklist. If a patient meets any single one of these criteria, they are classified as high risk and typically require hospital admission or further diagnostic workup.
The CHESS Mnemonic Criteria
A patient is considered High Risk if they possess any of the following clinical features:
C - Congestive Heart Failure: A known history of congestive heart failure (CHF).
H - Hematocrit less than 30%: Initial laboratory evaluation showing an objective anemia.
E - Electrocardiogram (ECG) Abnormal: Any non-sinus rhythm on the initial ECG or monitor, or any new acute ECG changes compared to a previous tracing.
S - Shortness of Breath: A subjective complaint or objective evidence of dyspnea accompanying the syncopal event.
S - Systolic Blood Pressure less than 90 mmHg: Hypotension documented during initial triage in the emergency department.
Clinical Interpretation and Performance
High Risk (Any Criteria Present): The patient carries a higher likelihood of short-term serious outcomes (such as severe arrhythmias, myocardial infarction, significant hemorrhage, or sudden death) and should generally be admitted for observation or accelerated evaluation.
Low Risk (Zero Criteria Present): In the original derivation studies, patients with a score of 0 were considered safe for discharge.
Clinical Note: While the original studies demonstrated a sensitivity near 96%, subsequent external validation studies showed lower real-world sensitivity (around 74% to 87%). Because it can miss potentially serious cardiac causes, the rule should always complement, rather than replace, careful clinical judgment.
San Francisco Syncope Rule References
Quinn, J. V., Stiell, I. G., McDermott, D. A., et al. (2004). Derivation of the San Francisco Syncope Rule to predict serious outcomes in patients with syncope. Annals of Emergency Medicine, 43(2), 224-232.
Quinn, J., McDermott, D., Stiell, I., et al. (2006). Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Annals of Emergency Medicine, 47(5), 448-454.
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