Written by Cobi Bissell (Peer Reviewed by Ketan Patel)
Spoon Feed
Presyncope has a 30-day serious cardiac outcome risk that is identical to patients with true syncope—despite presyncope patients being admitted less often and considered lower risk.
Dizzy logic: presyncope gets fewer beds, not less risk
The misperception that presyncope is lower risk than syncope impacts patient safety, disposition, and outcomes.
In this secondary analysis of the multicenter PACES cohort, 1,263 adults ≥40 years presenting with syncope (57%) or presyncope (43%) were compared. Serious cardiac outcomes at 30 days occurred in 4.7% of syncope and 5.2% of presyncope cases (OR 1.13; 95% CI 0.66–1.79). Physicians estimated lower risk for presyncope (mean 5.3%) than syncope (7.6%) and admitted fewer of these patients (38.2% vs. 49.5%), yet the adverse event rates were the same.
The study’s main limitation is that all six sites were urban academic centers, limited to adults ≥40, so findings may not generalize to younger patients or community EDs with fewer resources.
How does this change my practice?
Despite prior mixed studies, I’ve always taught that presyncope should be treated the same as syncope, and this study is affirming. Clinical presentation, history, and risk factors should be accounted for in both presentations. It’s crucial to examine both with the same level of scrutiny for major causes (mainly cardiac) and to risk-stratify and manage patients similarly.
Source
Serious Cardiac Outcomes and Physician Estimation of Risk in Emergency Department Patients With Presyncope Versus Syncope. Ann Emerg Med. 2025 Sep 23:S0196-0644(25)01155-2. doi: 10.1016/j.annemergmed.2025.08.014. Epub ahead of print. PMID: 40990887; PMCID: PMC12462893.
