Document Type : Original Article
- Afshin Amini 1
- Maryam Ahmadi Chegeni 1
- Zahra Soltanzadeh Khasraghi 1
- Mohammad Parsa Mahjoob 2
- Sina Shool 1
- Amir Ghabousian 3
- Rozita Khatamian Oskooi 4
- Saeed Safari 5, 6
1 Emergency Medicine Department, Imam Hossein Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Cardiology Department, Imam Hossein Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
4 Emergency Medicine Department, Imam Reza Hospital, Birgand University of Medical Sciences, Birgand, Iran
5 Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
6 Emergency Medicine Department, Shohadaye Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Objective: The significance of diagnosing the root reason for syncope and taking the
required preventive or treatment measures cannot be overlooked when it comes to
outcome prediction. This study endeavors to examine the role of proBNP in differentiating
cardiogenic and non-cardiogenic syncope in patients presenting to the emergency
Methods: We prospectively performed a cross-sectional study on patients presenting
with acute syncope. All the patients for this investigation were followed up until the
definite cause of their syncope (cardiac or non-cardiac) was diagnosed and the screening
performance characteristics of proBNP in differentiation of cardiogenic and noncardiogenic syncope were evaluated.
Results: Three hundred patients with syncope were studied (64.7% male). In the end,
the cause of syncope was determined to be cardiogenic in 133 cases (44.3%). The area
under the ROC curve of proBNP in the differentiation of cardiogenic syncope from noncardiogenic was estimated to be 78.9 (95% CI: 73.5 – 84.3). The optimal cut-off point for
proBNP in this regard was 143.5 pg/mL point. Sensitivity, specificity, positive and negative
predictive values, and positive and negative likelihood ratios of proBNP in the mentioned
cut-off point were 75.39% (95% CI: 67.61–82.73), 75.44% (95% CI: 68.07–81.62), 71.12%
(95% CI: 62.82–78.26), 79.74% (95% CI: 72.46–85.54), 2.46 (95% CI: 1.86–3.25), and 0.25
(95% CI: 0.18–0.34), respectively.
Conclusion: The accuracy of proBNP in differentiation of cardiogenic and non-cardiogenic
syncope is fair. ProBNP concentration equals to or higher than 143.5 pg/mL can differentiate
cardiogenic syncope from non-cardiogenic with 75% sensitivity and 76% specificity. It
seems that its use for this purpose should be considered with caution and along with other
risk score in differentiating cardiogenic and non-cardiogenic syncope; a cross-sectional study. Am J Emerg Med 2021; 50:675-8. doi: 10.1016/j.ajem.2021.07.034.
2. Arnar DO. Syncope in patients with structural heart disease. J Intern Med 2013; 273(4): 336-44. doi:10.1111/joim.12027.
3. Blanc JJ, L’Her C, Touiza A, Garo B, L’Her E, Mansourati J. Prospective evaluation and outcome of patients admitted for syncope over a 1 year period. Eur Heart J 2002; 23(10): 815-20. doi: 10.1053/euhj.2001.2975.
4. Fischer LM, Dutra JP, Mantovani A, Lima GG, Leiria TL. Predictors of hospitalization in patients with syncope assisted
in specialized cardiology hospital. Arq Bras Cardiol 2013;101(6): 480-6. doi: 10.5935/abc.20130206.
5. Dipaola F, Costantino G, Perego F, Borella M, Galli A, Cantoni G, et al. San Francisco Syncope Rule, Osservatorio
Epidemiologico sulla Sincope nel Lazio risk score, and clinical judgment in the assessment of short-term outcome of
syncope. Am J Emerg Med 2010; 28(4): 432-9. doi: 10.1016/j.ajem.2008.12.039.
6. Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, et al. Standardized-care pathway vs. usual management
of syncope patients presenting as emergencies at general hospitals. Europace 2006; 8(8): 644-50. doi: 10.1093/ europace/eul071.
7. Shen WK, Decker WW, Smars PA, Goyal DG, Walker AE, Hodge DO, et al. Syncope Evaluation in the Emergency
Department Study (SEEDS): a multidisciplinary approach to syncope management. Circulation 2004; 110(24): 3636-45.
8. Fonarow GC, Peacock WF, Phillips CO, Givertz MM, Lopatin M. Admission B-type natriuretic peptide levels and
in-hospital mortality in acute decompensated heart failure. J Am Coll Cardiol 2007; 49(19): 1943-50. doi: 10.1016/j.
9. Kenny RA, O’Shea D, Walker HF. Impact of a dedicated syncope and falls facility for older adults on emergency beds.
Age Ageing 2002; 31(4): 272-5. doi: 10.1093/ageing/31.4.272.
10. Kapoor WN. Evaluation and outcome of patients with syncope. Medicine (Baltimore) 1990; 69(3): 160-75. doi:
11. Grossman SA, Bar J, Fischer C, Lipsitz LA, Mottley L, Sands K, et al. Reducing admissions utilizing the Boston syncope criteria. J Emerg Med 2012; 42(3): 345-52. doi: 10.1016/j.
12. Middlekauff HR, Stevenson WG, Stevenson LW, Saxon LA. Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. J Am Coll Cardiol 1993; 21(1):110-6. doi: 10.1016/0735-1097(93)90724-f.
13. Middlekauff HR, Stevenson WG, Saxon LA. Prognosis after syncope: impact of left ventricular function. Am Heart J 1993; 125(1): 121-7. doi: 10.1016/0002-8703(93)90064-g.
14. Stryjewski PJ, Kuczaj A, Badacz L, Opara M, NowalanyKozielska E, Nowak J, et al. [Signification of NT-proBNP in the
differential diagnosis of syncope in adults]. Przegl Lek 2014; 71(5): 249-53.
15. Stryjewski PJ, Nessler B, Kuczaj A, Matusik P, Gilowski W, Nowak J, et al. The role of NT-proBNP in the diagnostics and differentiation of cardiac and reflex syncope in adults: relative importance to clinical presentation and medical examinations. J Interv Card Electrophysiol 2014; 41(1): 1-8. doi: 10.1007/s10840-014-9923-x.
16. Pfister R, Scholz M, Wielckens K, Erdmann E, Schneider CA. Use of NT-proBNP in routine testing and comparison
to BNP. Eur J Heart Fail 2004; 6(3): 289-93. doi: 10.1016/j.ejheart.2003.12.012.
17. Tanimoto K, Yukiiri K, Mizushige K, Takagi Y, Masugata H, Shinomiya K, et al. Usefulness of brain natriuretic peptide
as a marker for separating cardiac and noncardiac causes of syncope. Am J Cardiol 2004; 93(2): 228-30. doi: 10.1016/j.
18. Pfister R, Diedrichs H, Larbig R, Erdmann E, Schneider CA. NT-pro-BNP for differential diagnosis in patients with
syncope. Int J Cardiol 2009; 133(1): 51-4. doi: 10.1016/j.ijcard.2007.11.082.
19. Pfister R, Hagemeister J, Esser S, Hellmich M, Erdmann E, Schneider CA. NT-pro-BNP for diagnostic and prognostic
evaluation in patients hospitalized for syncope. Int J Cardiol 2012; 155(2): 268-72. doi: 10.1016/j.ijcard.2010.10.013.
20. du Fay de Lavallaz J, Badertscher P, Nestelberger T, Zimmermann T, Miró Ò, Salgado E, et al. B-type natriuretic
peptides and cardiac troponins for diagnosis and riskstratification of syncope. Circulation 2019; 139(21): 2403-18.