{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T16:21:41Z","timestamp":1773332501796,"version":"3.50.1"},"reference-count":69,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2025,11,7]],"date-time":"2025-11-07T00:00:00Z","timestamp":1762473600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2025,11,7]],"date-time":"2025-11-07T00:00:00Z","timestamp":1762473600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Academic Emergency Medicine"],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Syncope places a significant burden on emergency departments (EDs), often prompting extensive testing to exclude life\u2010threatening conditions. However, the diagnostic utility of troponin, B\u2010type natriuretic peptide (BNP), transthoracic echocardiography (TTE), and outpatient cardiac monitoring remains unclear.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This systematic review assessed the diagnostic accuracy of these tests in adults presenting with syncope. The research question was: In ED patients with syncope, does TTE, cardiac biomarkers (troponin, BNP), or outpatient arrhythmia monitoring, compared with no testing, improve outcomes within 30\u2009days? Primary outcomes included adverse events (death, arrhythmias, structural\/ischemic heart disease, and select non\u2010cardiac causes such as pulmonary embolism or aortic dissection) for biomarkers and diagnostic yield for TTE and monitoring. Sensitivity, specificity, and likelihood ratios (LR+ and LR\u2013) were calculated for biomarkers, while diagnostic yield with 95% CI was reported for TTE and monitoring. Risk of bias was assessed using JBI and QUADAS\u20102.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The database searches identified 1759 citations. After applying inclusion and exclusion criteria, 41 studies (21,557 patients) were included. Significant heterogeneity among the included trials (all with\n                      <jats:italic>I<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      \u2009&gt;\u200990%) precluded meta\u2010analysis. For BNP, LR+ ranged 1.4\u201347 and LR\u2013 0.06\u20130.4; for troponin, LR+ 1.9\u201311.2 and LR\u2013 0.2\u20130.9. TTE diagnostic yield was 0%\u201329% overall and 8%\u201328% in high\u2010risk groups. Outpatient monitoring yielded 1%\u201359% overall and 12%\u201342% in high\u2010risk patients.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In ED patients with syncope, the diagnostic accuracy and yield of cardiac biomarkers, TTE, and outpatient monitoring show substantial variability, largely due to differences in patient populations, outcome measures, and study methodologies. Based on the existing evidence, these modalities in isolation cannot be recommended for routine use in syncope evaluation. Among these tests, the diagnostic yield of TTE and outpatient monitoring is greater in patients with cardiac risk factors and could potentially contribute to a more accurate diagnosis.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/acem.70175","type":"journal-article","created":{"date-parts":[[2025,11,7]],"date-time":"2025-11-07T14:04:41Z","timestamp":1762524281000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cardiac Biomarkers, Echocardiography, and Outpatient Cardiac Monitoring for Evaluation of Emergency Department Patients With Syncope: A Systematic Review and Analysis of Direct Evidence for\n                    <scp>SAEM GRACE<\/scp>"],"prefix":"10.1111","volume":"33","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7303-3722","authenticated-orcid":false,"given":"Roshanak","family":"Benabbas","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine New York City Health and Hospitals\/Kings County Hospital  Brooklyn New York USA"},{"name":"Department of Emergency Medicine SUNY Downstate Health Sciences University  Brooklyn New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6427-986X","authenticated-orcid":false,"given":"Shahriar","family":"Zehtabchi","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine New York City Health and Hospitals\/Kings County Hospital  Brooklyn New York USA"},{"name":"Department of Emergency Medicine SUNY Downstate Health Sciences University  Brooklyn New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2021-2388","authenticated-orcid":false,"given":"Abel","family":"Wakai","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine Beaumont Hospital  Dublin Ireland"},{"name":"Emergency Care Research Unit (ECRU) Royal College of Surgeons in Ireland (RCSI)  Dublin Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5491-683X","authenticated-orcid":false,"given":"Robert","family":"Allen","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine Los Angeles General Medical Center  Los Angeles California USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1223-7502","authenticated-orcid":false,"given":"Ian S.","family":"deSouza","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine New York City Health and Hospitals\/Kings County Hospital  Brooklyn New York USA"},{"name":"Department of Emergency Medicine SUNY Downstate Health Sciences University  Brooklyn New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rebekah J.","family":"Richards","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine The Ohio State University Wexner Medical Center  Columbus Ohio USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Curley","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine Beaumont Hospital  Dublin Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eric","family":"Dunne","sequence":"additional","affiliation":[{"name":"Department of Medicine, Faculty of Health Sciences, Internal Medicine Residency Program, McMaster Children's Hospital McMaster University  Hamilton Ontario Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard","family":"Sinert","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine New York City Health and Hospitals\/Kings County Hospital  Brooklyn New York USA"},{"name":"Department of Emergency Medicine SUNY Downstate Health Sciences University  Brooklyn New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,11,7]]},"reference":[{"key":"e_1_2_8_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2015.04.030"},{"key":"e_1_2_8_3_1","doi-asserted-by":"publisher","DOI":"10.1111\/acem.15111"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1111\/acem.15041"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jen.2007.04.009"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.105.170274"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.119.040204"},{"key":"e_1_2_8_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.annemergmed.2018.06.047"},{"issue":"6","key":"e_1_2_8_9_1","first-page":"579","article-title":"Cardiac Imaging in Patients With Cardiac Syncope","volume":"65","author":"DI Fusco S. A.","year":"2017","journal-title":"Minerva Cardioangiologica"},{"key":"e_1_2_8_10_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13054-016-1208-6"},{"key":"e_1_2_8_11_1","doi-asserted-by":"publisher","DOI":"10.1177\/2047487316632628"},{"key":"e_1_2_8_12_1","doi-asserted-by":"publisher","DOI":"10.5811\/westjem.2013.11.18973"},{"key":"e_1_2_8_13_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.n71"},{"key":"e_1_2_8_14_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.332.7549.1089"},{"issue":"14","key":"e_1_2_8_15_1","first-page":"298","article-title":"The Development of a Critical Appraisal Tool for Use in Systematic Reviews Addressing Questions of Diagnostic Accuracy: A Systematic Review","volume":"13","author":"Munn Z.","year":"2015","journal-title":"JBI Database of Systematic Reviews and Implementation Reports"},{"key":"e_1_2_8_16_1","article-title":"The Revised JBI Critical Appraisal Tool for the Assessment of Risk of Bias for Analytical Cross\u2010Sectional Studies","author":"Barker T. H.","year":"2025","journal-title":"JBI Evidence Synthesis"},{"key":"e_1_2_8_17_1","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-155-8-201110180-00009"},{"key":"e_1_2_8_18_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0895-4356(03)00177-X"},{"key":"e_1_2_8_19_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12874-022-01788-2"},{"key":"e_1_2_8_20_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12874-021-01381-z"},{"key":"e_1_2_8_21_1","unstructured":"https:\/\/www.cochrane.org\/authors\/handbooks\u2010and\u2010manuals\/handbook. (2025)."},{"key":"e_1_2_8_22_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.annemergmed.2012.04.023"},{"key":"e_1_2_8_23_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.acvd.2023.07.006"},{"key":"e_1_2_8_24_1","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.1990.00390170103022"},{"key":"e_1_2_8_25_1","doi-asserted-by":"publisher","DOI":"10.1155\/2016\/1251637"},{"issue":"6","key":"e_1_2_8_26_1","first-page":"127","article-title":"Role of Echocardiography in Diagnostic Evaluation of Patients Admitted to Observation Unit","volume":"9","author":"Cheema M. A.","year":"2019","journal-title":"American Journal of Cardiovascular Disease"},{"key":"e_1_2_8_27_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jemermed.2014.01.018"},{"key":"e_1_2_8_28_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2014.09.021"},{"key":"e_1_2_8_29_1","doi-asserted-by":"publisher","DOI":"10.1111\/acem.13709"},{"key":"e_1_2_8_30_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2024.05.035"},{"key":"e_1_2_8_31_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2016.10.078"},{"key":"e_1_2_8_32_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1742-6731.2005.00678.x"},{"key":"e_1_2_8_33_1","doi-asserted-by":"publisher","DOI":"10.21037\/cdt.2016.03.06"},{"key":"e_1_2_8_34_1","doi-asserted-by":"publisher","DOI":"10.14423\/SMJ.0000000000000184"},{"key":"e_1_2_8_35_1","doi-asserted-by":"publisher","DOI":"10.3349\/ymj.2012.53.3.517"},{"key":"e_1_2_8_36_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijcard.2016.05.019"},{"key":"e_1_2_8_37_1","doi-asserted-by":"publisher","DOI":"10.1093\/qjmed\/hcm104"},{"key":"e_1_2_8_38_1","doi-asserted-by":"publisher","DOI":"10.1007\/s43678-024-00740-1"},{"key":"e_1_2_8_39_1","doi-asserted-by":"publisher","DOI":"10.1093\/europace\/euv311"},{"issue":"2","key":"e_1_2_8_40_1","first-page":"428","article-title":"Routine or Protocol Evaluation of Trauma Patients With Suspected Syncope Is Unnecessary","volume":"70","author":"Maung A. A.","year":"2011","journal-title":"Journal of Trauma"},{"key":"e_1_2_8_41_1","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2009.204"},{"key":"e_1_2_8_42_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.annemergmed.2023.12.009"},{"key":"e_1_2_8_43_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1540-8167.2007.00779.x"},{"key":"e_1_2_8_44_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijcard.2007.11.082"},{"key":"e_1_2_8_45_1","doi-asserted-by":"publisher","DOI":"10.12788\/jhm.3082"},{"key":"e_1_2_8_46_1","doi-asserted-by":"publisher","DOI":"10.1136\/emj.2007.048413"},{"key":"e_1_2_8_47_1","doi-asserted-by":"publisher","DOI":"10.1136\/emj.2008.068635"},{"key":"e_1_2_8_48_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2009.09.049"},{"key":"e_1_2_8_49_1","doi-asserted-by":"publisher","DOI":"10.1136\/emermed-2012-201332"},{"key":"e_1_2_8_50_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0002-9343(01)00797-5"},{"key":"e_1_2_8_51_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijcard.2004.03.016"},{"key":"e_1_2_8_52_1","doi-asserted-by":"publisher","DOI":"10.1111\/imj.16019"},{"key":"e_1_2_8_53_1","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.0000149236.92822.07"},{"key":"e_1_2_8_54_1","doi-asserted-by":"publisher","DOI":"10.1586\/14779072.2013.867807"},{"key":"e_1_2_8_55_1","doi-asserted-by":"publisher","DOI":"10.1136\/postgradmedj-2021-141416"},{"key":"e_1_2_8_56_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0002-9343(03)00233-X"},{"key":"e_1_2_8_57_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10840-014-9923-x"},{"key":"e_1_2_8_58_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1540-8159.2006.00530.x"},{"key":"e_1_2_8_59_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjcard.2003.09.048"},{"key":"e_1_2_8_60_1","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000034064"},{"key":"e_1_2_8_61_1","doi-asserted-by":"publisher","DOI":"10.7326\/M19-3515"},{"issue":"2","key":"e_1_2_8_62_1","first-page":"110","article-title":"Diagnostic Yield of Syncope Investigation (Initiated) in the Emergency Department: A Pilot Study","volume":"66","author":"Vanbrabant P.","year":"2011","journal-title":"Acta Clinica Belgica"},{"key":"e_1_2_8_63_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1553-2712.2012.01375.x"},{"key":"e_1_2_8_64_1","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehp298"},{"key":"e_1_2_8_65_1","doi-asserted-by":"publisher","DOI":"10.1111\/1742-6723.12937"},{"key":"e_1_2_8_66_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11739-015-1318-1"},{"key":"e_1_2_8_67_1","doi-asserted-by":"publisher","DOI":"10.1093\/ehjci\/jew333"},{"key":"e_1_2_8_68_1","doi-asserted-by":"publisher","DOI":"10.5811\/westjem.2018.2.37100"},{"key":"e_1_2_8_69_1","doi-asserted-by":"publisher","DOI":"10.12788\/jhm.2864"},{"issue":"5","key":"e_1_2_8_70_1","first-page":"e60","article-title":"2017 ACC\/AHA\/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society","volume":"136","author":"Shen W. K.","year":"2017","journal-title":"Circulation"}],"container-title":["Academic Emergency Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/acem.70175","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/acem.70175","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/acem.70175","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T04:16:02Z","timestamp":1773288962000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/acem.70175"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,7]]},"references-count":69,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2026,2]]}},"alternative-id":["10.1111\/acem.70175"],"URL":"https:\/\/doi.org\/10.1111\/acem.70175","archive":["Portico"],"relation":{},"ISSN":["1069-6563","1553-2712"],"issn-type":[{"value":"1069-6563","type":"print"},{"value":"1553-2712","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,7]]},"assertion":[{"value":"2025-05-11","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-10-07","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-11-07","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70175"}}