San Francisco Syncope Rule

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The San Francisco Syncope Rule (SFSR) is a simple rule for evaluating the risk of adverse outcomes in patient who present with fainting or syncope.

The mnemonic for features of the rule is CHESS:

C - History of congestive heart failure

H - Hematocrit < 30%

E - Abnormal ECG

S - Shortness of breath

S - Triage systolic blood pressure < 90

A patient with any of the above measures is considered at high risk for a serious outcome such as death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return Emergency Department visit and hospitalization for a related event.

SFSR has a sensitivity of 74-98% and specificity of 56%.[1][2] This means that in patients with none of the above criteria, 74-98% had no serious outcome and may be considered as suitable candidates for outpatient monitoring. Syncope accounts for 1-2% emergency department visits. Half are hospitalized and of these, 50% have unclear diagnosis and 85% will be simply monitored. Given these statistics, the SFSR will help reduce inefficient admissions.


  1. ^ Quinn J; McDermott D; Stiell I; Kohn M; Wells G (May 2006). "Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes". Ann Emerg Med. 47 (5): 448–54. doi:10.1016/j.annemergmed.2005.11.019. PMID 16631985. 
  2. ^ Birnbaum A; Esses D; Bijur P; Wollowitz A; Gallagher EJ (February 2008). "Failure to Validate the San Francisco Syncope Rule in an Independent Emergency Department Population". Ann Emerg Med. 52 (2): 151–9. doi:10.1016/j.annemergmed.2007.12.007. PMID 18282636.