To assess the clinical presentation and acute management of patients with transient loss of consciousness (T-LOC) in the emergency department (ED).

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1 Epdemologcal characterstcs and dagnostc approach n patents admtted to the emergency room for transent loss of conscousness: Group for Syncope Study n the Emergency Room (GESINUR) study Gonzalo Baron-Esquvas, Jesús Martínez-Ad ay, Alfonso Martn, Angel Moya, Roberto Garca-Cvera, M. Paz López-Chcharro, María Martín-Méndez, Carmen del Arco, and Pedro Laguna Ams Methods and results Concluson Keywords To assess the clncal presentaton and acute management of patents wth transent loss of conscousness (T-LOC) n the emergency department (ED). A mult-centre prospectve observatonal study was carred out n 19 Spansh hosptals over 1 month. The patents ncluded were >14 years old and were admtted to the ED because of an epsode of T-LOC. Questonnares and correspondng electrocardograms (ECGs) were revewed by a Steerng Commttee (SC) to unfy dagnostc crtera, evaluate adherence to gudelnes, and dagnose correctly the ECGs. We ncluded 1419 patents (prevalence, 1.14%). ECG was performed n 1335 patents (94%) n the ED: 498 (37.3%) ECGs were classfed as abnormal. The postve dagnostc yeld ranged from % for the chest X-ray to 12% for the orthostatc test. In the ED, 1217 (86%) patents receved a fnal dagnoss of syncope, whereas the remanng 22 (14%) were dagnosed of non-syncopal transent loss of conscousness (T-LOC). After fnal revew by the SC, 18 patents (76%) were dagnosed of syncope, whereas 339 (24%) were dagnosed of T-LOC (P ). Syncope was dagnosed correctly n 84% of patents. Only 25% of patents wth T-LOC were admtted to hosptals. Adherence to clncal gudelnes for syncope management was low; many dagnostc tests were performed wth low dagnostc yeld. Important dfferences were observed between syncope dagnoses at the ED and by SC decson. Syncope Emergency department Transent loss of conscousness Introducton The hgh prevalence of patents wth transent loss of conscousness (T-LOC) at emergency departments (EDs) s well known. Several studes have quantfed the ncdence from.9 to 3%, although most agree on the lower rate. Of these patents, 43-98% wll be hosptalzed. ~ Nevertheless, most studes of T-LOC n the ED reflect the experence of only one centre or of just a few local centres, as n the OESIL study and RESASTER study. ' Thus, the present study ntroduced to multple centres the European Socety of Cardology (ESC) gudelnes for the management of patents wth T-LOC n the ED. Ths study was performed n homogeneous hosptals that are ncluded n a publc healthcare system (PHS).

2 The Group for Syncope Study n the ER (GESINUR) study stems from a co-ordnated work scheme drawn up by the Scentfc Commttee of the Syncope Task Force Group of the Spansh Socety of Cardology and the Arrhythma Secton from the Spansh Socety of Emergences. GESINUR s an observatonal study that descrbes the clncal and epdemologcal characterstcs of patents admtted to the ED wth T-LOC as well as the current dagnostc approach and compares these fndngs wth the standardzed dagnoses followng the ESC gudelnes. Methods Partcpatng centres The GESINUR study was a mult-centre prospectve observatonal study carred out n 19 Spansh hosptals n the same PHS from November 15 to December 15. We ncluded all patents admtted to the ED due to an epsode of T-LOC (defned as a sudden and transtory LOC wth complete recovery) occurrng wthn the 24 h pror to ther admsson. Each hosptal has a 24-h ED, a Cardology Department, a Coronary Unt, and, typcally, an Electrophysology Unt Defntons Accordng to the clncal characterstcs and the ESC gudelnes for syncope, patents were dvded nto two large groups: syncope and non-syncopal transent loss of conscousness (T-LOC). Syncope was defned as a transent, self-lmted LOC that usually leads to a fall because of transent global cerebral hypoperfuson. On the other hand, the T-LOC group ncluded those patents wth T-LOC, but wthout syncope. 6 Abnormal results of addtonal tests performed n the ED were consdered dagnostc when potentally related to the cause of T-LOC Cohort study Patent selecton crtera We ncluded all patents >14 years who attended the ED due to T-LOC. Patents wth the followng condtons were excluded: T-LOC due to cranum-encephalc trauma, an epsode of sudden cardac death caused by asystola or ventrcular fbrllaton, or evdent neurologcal epsodes wth cerebrovascular accdent and presyncope. Objectves The man objectves of the GESINUR study were to analyse the current protocols for the examnaton of T-LOC patents at the ED, to study syncope epdemology n the PHS, to determne the ncdence and characterstcs of syncope, and pont out possble errors n ts dagnostc evaluaton. In addton, adherence to the ESC gudelnes for the dagnoss of syncope n the daly practce was studed. 6 Data collecton A questonnare was completed for each patent who met the enrolment crtera. Addtonally, we hghly recommended that a copy of the electrocardogram (ECG) performed on the patent be attached to each questonnare, for subsequent analyss by the Steerng Commttee (SC) of the GESINUR study. However, the other complementary dagnostc tests were decded freely by each physcan. Each hosptal chose a physcan who was responsble for checkng daly the ncluson of all patents wth T-LOC who attended the ED and for completng any unfnshed questonnare. Data revew In order to evaluate the adherence of the dagnoss to ESC gudelnes, each questonnare and the correspondng ECG were revewed by the SC and, f needed, the dagnoss was reassgned. Statstcal analyss Data were collected prospectvely and analysed. Contnuous varables were expressed as medans (nterquartle range) f ther dstrbutons were not normal and as means + SDs when ther dstrbutons were normal. Statstcal comparsons of contnuous varables between groups were performed by t-test or by the non-parametrc Mann-Whtney U test for normal and non-normal dstrbutons, respectvely. Comparsons between quanttatve and qualtatve varables were performed by means of ANOVA test. Comparson between proportons was by means of the x test and Yates correcton, when approprate. All reported P-values are two-taled, and P <.5 was consdered sgnfcant. Data were analysed wth V. 11. SPSS software (SPSS, Chcago, IL, USA). Results General characterstcs Durng the study perod, patents were admtted to the ED n 19 centres, of whch 1419 (1.14%) were dagnosed of T-LOC and ncluded n the study. Of these patents, 1217 were dagnosed of syncope (syncope group), whereas 22 were dagnosed of T-LOC (T-LOC group), whch ncluded 36 cases of T-LOC caused by eplepsy and 166 caused by dverse or unknown causes. Of the 1419 patents, only 394 (28%) requred therapeutc nterventon. Hosptal admsson was decded for 36 patents (25%): Cardology, 92 (6%); Neurology, 25 (2%); Internal Medcne, 47 (3%); other, 55 (4%); and Observatonal Unt, 141 (1%). Twelve patents (.85%) ded n the ED. The remanng 159 patents (75%) were dscharged after a medan of 4 (2-6) h n the ED. The epdemologc features of the study populaton are summarzed n Table 1, accordng to fnal dagnoss n the ED (T-LOC or syncope). The medan age was years, and 732 patents (51.6%) were women, who were younger than the men ( vs years, P<.1). The populaton pyramd s shown n Fgure 1. Of the 1419 patents, 233 (16%) had a prevous hstory of heart dsease, and 147 (1%) presented arrhythma hstory, wth atral fbrllaton n 98 (67%) patents beng the most prevalent. When patent groups were compared accordng to fnal dagnoss, no sgnfcant epdemologcal dfferences were detected between the T-LOC and syncope groups, except n the percentage of patents wth a hstory of neurologcal dsease (23 vs. 1%, respectvely; P ) and of other assocated dseases (35 vs. 25%, respectvely; P <.3). Clncal characterstcs The clncal characterstcs that defned T-LOC were collected carefully and are shown n Table 2. Wth regard to prodromal symptoms, the analyss of the cardac syncope subgroup s especally nterestng. Of the 141 patents (1% of the total) dagnosed wth cardac syncope (arrhythmc and cardopulmonary), 83 (59%) presented prodromal symptoms: palptatons,

3 Table I General characterstcs of patents Total (n = 1419) Syncope (n = 1217) T-LOC (n = 22) P Female (%) Age ± ± ± Male ± ± Female 55.3 ± ± ± Frst loss of conscousness 898 (63%) 779 (64%) 119(58%).289 Presyncope 178(18.6%) 161 (19.2%) 17 (14.5%).227 Tme n emergency department (h) 4. (2.-6.) 3. (2.-6.) 4.(1.- 7.).846 Recovery Spontaneous Post-CPR 1364(96.1%) 12(.8%) 1189(97.7%) 5 (.4%) 175 (86.6% 7 (3.5%) Prevous medcal hstory 46 (29%) 338 (28%) 68 (34%).88 Heart dsease 233 (16.4%) 196(16%) 37(18%).435 Ischaemc 14(6.1%) 117(59.7%) 23 (62.2%) Valvular 34 (14.6%) 3(15.3%) 4(1.8%) Hypertensve 34 (14.6%) 27(13.8%) 7(18.9%) Dlated 1(4.3%) 1(5.1%) Hypertrophc 1 (.4%) 1 (.5%).411 Congental 3 (1.3%) Congestve heart falure 7(3%) 6(3.1%) 1 (2.7%) Multple 4(1.7%) 2(1%) 2 (5.4%) Documented arrhtyhmas 147(1%) 123 (1%) 24(11%).443 Atral fbrllaton 98 (66.7%) 81 (65.9%) 17 (7.8%) Supraventrcular tachycarda 3 (2%) 3 (2.4%) Atral flutter Ventrcular tachycarda/fbrllaton 4 (2.7%) 4 (2.7%) 2(1.6%) 4 (3.3%) 2 (8.3%).321 Snus node dsease 4 (2.7%) 4 (3.3%) AV block 7 (4.8%) 7 (5.7%) Prevous pacemaker mplant 27 (18.4%) 22(17.9%) 5 (2.8%) Neurologcal dsorder/dsease 173 (12%) 125 (1%) 48 (23%) StrokeATIA 91 (52.6%) 7 (56%) 21 (43.8%) Eplepsy 22 (12.7%) 13 (1.4%) 9(18.8%) Neoplasa 4 (2.3%) 2(1.6%) 2 (4.2%) Multple scleross 2(1.2%) 1 (.8%) 1 (2.1%).211 Parknson's dsease 17(9.8%) 14(11.2%) 3 (6.3%) Autonomc nervous system dsease 3 (1.7%) 1 (.8%) 2 (4.2%) Dementa 21 (12.1%) 13 (1.4%) 8(16.7%) Others 13 (7.5%) 11 (8.8%) 2 (4.2%) Hypertenson 358 (25.2%) 34 (25%) 54 (26.7%).595 Others 382 (26%) 31(25%) 72 (35%).3 Dabetes melltus 163 (11.5%) 132(1.8%) 31 (15.3%) COPD 5 (3.5%) 39 (2.7%) 11 (15.3%) Psychatrc dsorders 43 (2.7%) 35 (2.9%) 8 (4.%).929 Cancer 31 (2.2%) 26 (2.1%) 5 (2.5%) T-LOC, non-sustaned transent loss of conscousness; CPR, cardopulmonary resusctaton; AV block, atroventrcular block; TIA, transent schaemc attack; COPD, chronc obstructve pulmonary dsease. 17%; lght-headedness/sweatng/nausea, 42%; dyspnoea, 1%; chest pan, 16%; and other, 16%. Palptatons and chest pan were sgnfcantly more frequent n the cardac syncope subgroup when comparng wth non-cardac syncope (19.1 vs. 2.9%; P <.1). Two hundred and sxty-sx patents (19%) suffered mld trauma assocated wth T-LOC, whereas 22 patents (2%) experenced severe trauma. T-LOC recovery was complete and wthout sequel n 1187 patents (83%). The remanng patents presented confuson (124; 9%), sweatng (42; 3%), transent neurologcal

4 > , I o> 45^(9 "* U- M H I [_ J zz 1 Men-Women I l l 1 t~^ : r Number of patents Fgure Age and sex pyramd for syncope ncdence n GESINUR Study. dsorder (14; 1%), vertgo (13; 1%), and retrograde amnesa (14; 1%). Clncal evaluaton Upon admsson to the ED, all patents underwent a clncal work-up. Durng the evaluaton, 1332 patents (93.9%) were conscous and orented, and 87 patents (5%) were confused. Only 33 patents (2%) had focal neurologcal dsorders. Dagnostc tests ECG was performed on 1335 patents (94%). Of the 1335 ECGs, 498 (37.3%) were classfed as abnormal at the ED. The tests performed and ther values n achevng fnal T-LOC dagnoss are reported n Table 3. Due to the fact that ths was an observatonal study, the crtera for consderng a specfc test to be dagnostc was not pre-specfed, and was left to the current practce of each centre. The postve dagnostc yeld ranged from % for the chest X-ray to 12% for the orthostatc test. Some tests showed dfferent dagnostc yelds n the syncope and T-LOC groups. For example, a bran CT scan was performed n 9% of patents wth syncope and showed a dagnostc yeld of %. In contrast, n the T-LOC group a bran CT scan was performed n 37% of patents, wth a dagnostc yeld of 1.7%. Furthermore, the ECG showed a dagnostc yeld of 7.7%, wth a range from 8.9% n the syncope group to % n the T-LOC group. Fnal dagnoss at the ED The fnal dagnoss at the ED was syncope n 1217 (86%) patents and T-LOC n the remander (22 patents; 14%). The cause of syncope was unexplaned n 346 patents (28.5%), whereas for the remanng 871 patents (71.5%), the determned cause was neurally medated (54), orthostatc (98), arrhythmc (89), cardopulmonary (52), steal syndrome (1), stuatonal (74), and non-specfed aetology (17). As mentoned prevously, T-LOC was dagnosed n 22 patents (14%): 87 wth unexplaned cause, 36 due to eplepsy, and 79 assocated wth other pathologes (23 stroke, 5 bran cancer, 7 toxc ngeston, 14 metabolc alteratons, 5 dzzness, 6 psychatrc dsorders, 2 blood haemorrhage, and 17 other pathologes). Fnal revewed dagnoss All patent data sources (questonnare, ECG) were revewed by the SC to confrm that the dagnoss n the ED was made accordng to the ESC gudelnes and to acheve a fnal revewed dagnoss. The revewed dagnoss showed statstcally sgnfcant dfferences wth the dagnoss made at the ED (P ). The fnal revewed dagnoss was syncope n 18 patents (76%) and T-LOC n 339 patents (24%). Therefore, syncope was dagnosed correctly n 84% of patents. Dfferences found between dagnoss at the ED and the revewed dagnoss by the SC are showed n Fgure 2. Dscusson The GESINUR study was the frst large, multcentre, prospectve, observatonal study of syncope to be performed snce the ESC gudelnes for syncope were publshed n 21. Ths study provdes mportant data about the management of syncope and adherence to the relevant gudelnes n a country (Span) wth a very homogenous PHS. General characterstcs In Spansh centres, the proporton of patents admtted to the ED due to T-LOC was 1.14%. These data are consstent wth those reported n Europe and the USA. ~ ' However, the proporton of patents wth T-LOC who were admtted to hosptal n our country was only 25%, whch s much less than the 43 98% reported by other authors. ' Of the patents n our study who were admtted to hosptal, 1% were admtted to short-term, n-hosptal stay unts. Despte ths lower-cost approach to T-LOC management n Span, patent safety was very smlar to that reported by other authors for study populatons smlar n age and prevous medcal hstory, as confrmed by Morag et oí. and by prelmnary follow-up data from the GESINUR-1 study.

5 Table 2 Clncal characterstcs of epsode Total (n = 1419) Syncope (n = 1217) T-LOC [n = 22) P Prodromal symptoms None 59 (41.6%) 466 (38.3%) 124(61.4%) Palptatons 37 (2.6%) 31 (2.5%) 6(3%) Lght-headedness/sweatng/nausea 678 (47.8%) 623 (51.2%) 55 (27.2%) Dyspnea 23 (1.6%) 22 (1.8%) 1 (.5%) Chest pan 32 (2.2%) 27 (2.2%) 5 (2.5%) Others 33 (2.3%) 25 (2%) 8(4%) Multple 26 (1.8%) 23 (1.9%) Precptatng/trggerng factors None 79 (5.%) 572 (47.%) 137(67.8%) Pan 111 (7.8%) 16 (8.7%) 5 (2.5%) Prolonged standng 19(7.7%) 13 (8.5%) 6 (3.%) Crowded or warm places 88 (6.2%) 8 (6.6%) 8 (4.%) Emotons 74 (5.2%) 59 (4.8%) 15 (7.4%) Drugs 67 (4.7%) 59 (4.8%) 8 (4.%) Stuatonal 11 (7.1%) 97 (8.%) 4 (2.%) Post-stress/exercse 45 (3.2%) 41 (3.4%) 4 (2.%) Sght of blood 29 (2.%) 28 (2.3%) 1 (.5%) Other 86 (6.1%) 72 (5.9%) 14 (6.9%) 1 Neurologcal accompanyng symptoms Convulsons 63 (4.4%) 3 (2.5%) 33 (16.3%) 1 Head rotaton 12 (.8%) 9 (.7%).511 Tongue btng 16 (1.1%) 8 (.7%) 8(4%) 1 Cyanoss 13 (.9%) 7 (.6%) 3 (2.5%).4 1 Trauma None 1131 (79.7%) 97 (79.7%) 161 (79.7%) Mld 266(18.7%) 228 (18.7%) 38(18.8%) Severe 22(1.6%) 19 (1.6%) Epsode duraton Unknown 391 (27.6%) 324 (26.6%) 67 (33.2%) <3 mn 78 (49.9%) 64 (52.6%) 68 (33.7%) 3 5 mn 179(12.6%) 149 (12.2%) 3 (14.9%) >5 mn 141 (9.9%) 14 (8.5%) 37(18.3%) Recovery Spontaneous 1364(96.1%) 1189 (97.7%) 175 (86.6%) After manoeuvre 12 (.8%) 5 (.4%) 7 (3.5%) Not specfed 43 (3.%) 23 (1.9%) 2 (9.9%) T-LOC, non-sustaned transent loss of conscousness. Interestngly, the present study revealed the dffculty n clearly defnng syncope. Recently, the Ad Hoc Syncope Consortum stressed ths ssue. 12 We dd not provde any defnton of syncope n advance so that the physcans at the ED could decde freely whether T-LOC was due to syncope. Of the 1419 patents presentng T-LOC at the ED n the GESINUR study, 1217 were dagnosed wth syncope. However, careful revew of the questonnares dmnshed the number to 18, whch ndcates a 16% dscordance. Falure to dstngush syncope from other forms of T-LOC s a common mstake, as detaled n other relevant medcal wrtngs. 13,14 Our results reveal that physcans need clear, practcal, and accurate defntons of syncope to acheve an accurate dagnostc evaluaton. Clncal characterstcs In the present study, women who attended the ED were younger than men ( vs years, P =.1), whch suggests a greater prevalence of syncope among younger women than younger men (Fgure 1). In accordance wth prevous studes, >63% of patents were admtted to the ED due to ther frst syncopal epsode. 7-1 There were no dfferences n prevous medcal hstory between the groups dagnosed at the ED as syncope or T-LOC, but there were dfferences n the proporton of neurologcal and of other assocated dseases (Table 1). The detaled data collecton recommended by the protocol detected precptant or trggerng factors n 5% of total patents and prodromal symptoms

6 Table 3 Performed tests and ther dagnostc values n 1419 patents Total (n = 1419) Syncope (n = 1217) T-LOC (n = 22) P-value Patents Dagnosed Patents Dagnosed Patents Dagnosed 1 Patents 1378 (97.1%) 444 (32.2%) 1186 (97.5%) 439 (37.%) 192(95.%) 5 (2.6%) Test done Dagnostc Test done Dagnostc Test done Dagnostc Total tests 423 (283.5%) 147 (3.7%) 3434 (282.2%) 136(4.%) 589 (291.6%) 11 (1.9%).12 Carotd snus massage 6 (.4%) 6 (.5%) NA Orthostatc test 66 (4.7%) 8 (12.1%) 56 (4.6%) 8 (14.3%) 1(5.%) Basc blood chemstry 15 (7.8%) 7 (.7%) 854 (7.2%) 5 (.6%) 151 (74.8%) 2 (1.3%) Enzymes 412(29.%) 13 (3.2%) 368 (3.2%) 12 (3.3%) 44(21.8%) 1 (2.3%) Chest X-ray 736(51.9%) 632(51.9%) 14(51.5%) NA ECG contnuous montorng 234(16.5%) 4(1.7%) 28(171%) 4(1.9%) 26 (12.9%) Echocardography 28 (2.%) 2(7.1%) 25 (2.1%) 2 (8.%) Bran CT scan 184(13.%) 8 (4.3%) 19(9.%) 75 (37.1%) 8 (1.7%) Thorax CT scan 17(1.2%) 2(11.8%) 13 (1.1%) 2(15.4%) 4 (2.%) ECG 1335 (94.1%) 13 (7.7%) 1163 (95.6%) 13 (8.9%) 172(85.1%) Other tests 118(8.3%) (.%) 88 (7.2%) (.%) 3 (14.9%) (.%) T-LOC, non-sustaned transent loss of conscousness; NA, not applcable;, not sgnfcant; ECG, electrocardogram ; CT, computed axal tomography ER(n=1217) Revewed by SC (n=18) I I Neu rally medated Unexplaned Orthostatc Arrhythmc Stuatonal Cardopulmonary Steal syndrome Netspecfed Fgure 2 Dfferences between dagnoses made n the emergency department and by the Steerng Commttee. n 58%, whch renforces the mportance of performng a detaled clncal hstory to ncrease the dagnoss rate. Nevertheless, the cardogenc syncope group showed a smlar percentage of prodromal symptoms (59%), whch confrms the results reported by Suzuk et oí. 15 that 68% of cardogenc syncope patents had prodromes. In our study, palptatons and chest pan were more frequent n the cardogenc syncope group as prevously showed. The trauma rate n patents wth T-LOC was 2%, but only 2% of these condtons were consdered severe. Dagnostc tests As other authors reported prevously, the use of dagnostc tests s far from the ESC gudelne recommendatons. 2,6,1 The present multcentre study, whch took place n a natonal PHS, showed once agan that several tests wth low dagnostc yeld, such as the chest X-ray, are performed daly. However, other Class I ndcaton tests are unusual, such as carotd snus massage that was only performed n.4% of patents, whch makes t dffcult to evaluate ther dagnostc value (%). An orthostatc test had an

7 acceptable overall dagnostc yeld (12%) and seemed to be able to dscrmnate both groups. A smple ECG n syncope patents s a Class I ndcaton n the ESC and n the Amercan gudelnes, but s not wdely performed, even n those patents at hgh rsk of syncope (.e. older or hosptalzed patents). ' ' For ths reason, our protocol recommended the performance of an ECG n all patents. Protocol adherence was 94%. An abnormal ECG was found n 37.3% of patents, wth a dagnostc yeld of 7.7%. Other frequently performed tests, such as bran CT scan, showed low dagnostc yelds, rangng from % for the syncope group to 1.6% for the T-LOC group. Gglo et oí. descrbed an experence wth 128 patents admtted to the ED due to syncope. Forty-four (34.3%) of these patents had a bran CT scan, whch led to just one postve result and confrmed the low dagnostc value of the technque for these patents. Systematc applcaton of the clncal gudelnes would decrease the number of tests performed to acheve a fnal dagnoss. Conclusons Ths study confrms that the rate of patents attended at the ED for T-LOC n our country s qute smlar to that n other seres. We conclude that clncal gudelne adherence s stll low, whch results n the performance of a hgh number of dagnostc tests wth low dagnostc yeld and leads to mportant dfferences n fnal syncope dagnoss. Whether the low hosptal admsson rate n our country has any mpact on long-term outcome s a matter to be addressed by ongong studes. Conflct of nterest: none declared. Fundng The study was supported by a grant from Medtronc Ibérca, S.A., CRDM Dvson, Madrd, Span. Ths study was offcally endorsed by the Arrhythma secton of the Spansh Socety of Cardology and by the Arrhythma Dvson of the Spansh Socety of Emergency Medcne. Fnal dagnoss Despte sgnfcant dfferences between the EDs and the revewed fnal dagnoses, 84% of 1419 patents were correctly dagnosed wth syncope. However, sgnfcant dscrepances n syncope dagnoss were detected; the most mportant dfference was the classfcaton of neurally medated syncope. Only 32.8% of the neurally medated syncope dagnoses were consstent between the ER and the SC. At the ED, 38% of patents were dagnosed wth neurally medated syncope, whereas the SC only dentfed 17%. Ths relatvely large dscrepancy s due to the adherence by the SC to the ESC gudelne crtera that requre prodromal symptoms and precptants or trggerng factors to dagnose a neurally medated syncope. In the ED, neurally medated syncope was dagnosed usng only one of these two crtera. For ths reason, the rate of unexplaned syncope as determned by the SC ncreased from 24 to 42%. Ths fndng could be relevant n patent management and hosptal admsson and, furthermore, n the prognostc value as demonstrated by Soterades et oí. Long-term follow-up of these patents wll reveal whether dagnostc crtera accordng to the gudelnes are adequate or too restrctve. Although there were fewer dscrepances n those syncopes wth hgher prognostc mportance, only 65% of dysrhythmc syncope and 54% of cardopulmonary syncope were correctly dagnosed. Study lmtatons Ths multcentre study collected data from patents wth T-LOC who were admtted to the ED n a specfc homogeneous PHS, but some varatons cannot be dsregarded, ncludng those related to syncope management n several centres. Nevertheless, the hgh number of studed patents should homogenze the results. The GESINUR study was performed only at the ED, and some types of syncope lkely are not represented, whch probably led to underestmaton of neurally medated syncope. Fnally, an equtable number of patent questonnares and ECG was revewed by each member of the SC. Only those patents of uncertan dagnoss were revewed by all members to reach a dagnoss by consensus. Appendx 1 Steerng Commttee: Angel Moya, Roberto García-Overa, Jesús Martínez-Alday, Gonzalo Barón-Esquvas, Alfonso Martín-Martínez, Carmen del Arco-Galán, Pedro Laguna del Estal. Scentfc Commttee: Angel Moya, Roberto García-Cvera, Jesús Martínez-Alday, Gonzalo Barón-Esquvas. GESINUR partcpatng centres and nvestgators (n order of number of patents enrolled): H.U. Vrgen del Rocío, Sevlla: A. Caballero, S. Berraquero, M. Dale, M. Frutos, M.V. Mogollón, R. Pérez, N. Romero; H. Morales Messeguer, Murca: E. Martnez; H.U. Vrgen de las Neves, Granada: J. Sánchez, AE. Delgado, H. Muñoz, F. Gutérrez, M. López, J. Morata, S. Hernandez, M.M. Escobar, T. Jerez, A. Tello; H. U. Carlos Haya, Málaga: C. Suero, R. Seara, P González, C. López, R. Navdad, J.M. Fernández, M. Salguero, M. Valero, M.S. Duran, A. Martín, J. Muñoz; H.U. de la Prncesa, Madrd: T. Isasa, A. Pzarro, A. Amengual, M. Junquera, E. Contreras, J.M. Ruz, N. Vllalba, P Múgca, M.J. Esteve; H. Móstoles, Madrd: J.F. Peranes, A. Ovejero, J.F. Hoyo, O. Alvarez, M.M. Lanez, L. Martínez, F. Fernández, H. Matamoros, R. Fallos, R. García, S. Sánchez; F.H. Costa del Sol, Marbella, Málaga: R. Molna; H. U. Puerta de Herro, Madrd: M. Moya, R. Salgado, S. Calabrese, J. Marrero, J. Gómez, C. Mascías, Y. Romero, C. Manez, F. Rvas, G Pérez, C. Montero; H. Clnc Provncal, Barcelona: B. Coll-Vnent, M. Junyent, A. Garca, G Garca, S. Quesada; F. H. Alcorcón, Madrd: B. Rodríguez, J.A. Satue, S. Gonzalo, M.A. Ortega, Al. Ocaña, M.l. Albo, A. Torre, M.J. Venegas, M.C.C. Tejero; H. Vrgen del Camno, Pamplona: J.M. Arraza, A. Lozano, R. Medna, I. Moreno, M. Rodrgo, R. Sobrado, F.J. Urruta, J.J. Varo, J. Sesma, B. Gorraz, E. Jménez, J.M. Labandera, W. Soler, A. Larequ, J. Aldaz, C. Merno, V. Ruz-Eguno, S. Burusco, I. Berrozpe, J. Ibañez, J. Abad; H. Clínco U., Valenca: M. Hortoneda, M. Sánchez, J.V Balaguer; H. Severo Ochoa, Leganés, Madrd: S. Artllo, J. Bascuñana, J. Olalla, J. Rojas, M.J. Sanz, N. Ventosa, P Suarez, L Mancebo; C. H. Donosta, San Sebastán, Gupúzcoa: M. Canco, C. Ora, C. Marcellán, D. López, I. Ventura, M. Basabe; H. U. Valí D'Hebrón, Barcelona: V Bazán, E. Ruz; H. U. San Juan, Alcante: F.J. Navarro; F. H. de Ceza, Murca: P Pnera, J.J. Gménez, J.J. Parrlla, M.J. Martínez, J.M. Almela, F. Martínez, M. Vargas, C. Escudero, J. Gménez; H.U. Valme, Sevlla: C. León, F. Ruz, T. Carrera, M. Lucas; H.U. Santa Creu Sant Pau, Barcelona: M. Santaló, S. Bento. Study management: M.P López-Chcharro.

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