Syncope, or transient loss of consciousness, is one of the most frequent reasons for emergency department visits. While most causes are benign, a significant percentage of patients may harbor potentially life-threatening conditions such as arrhythmias, myocardial infarction, or internal bleeding. The challenge for clinicians lies in distinguishing which patients can be safely discharged and which require hospital admission.
One of the clinical decision tools developed to address this problem is the ROSE Rule, summarized by the mnemonic BRACES. This article explores the origin, components, evidence base, and application of the ROSE Rule in modern clinical practice.
What is the ROSE Rule?
The ROSE (Risk Stratification of Syncope in the Emergency Department) Rule is a validated clinical tool designed to identify patients with syncope who are at high risk of serious adverse outcomes within 1 month. It was first derived and validated in the UK and remains a practical guide for emergency physicians worldwide.
The strength of the ROSE Rule lies in its simplicity. Instead of relying on complex scoring systems, it uses six easily measurable clinical and laboratory features. If a patient with syncope presents with any one of these features, hospital admission is strongly recommended.
The BRACES Mnemonic
The components of the ROSE Rule are remembered using the mnemonic BRACES:
- B – BNP level ≥ 300 pg/ml
- B – Bradycardia ≤ 50 bpm in the emergency department (or pre-hospital setting)
- R – Rectal examination showing fecal occult blood (gastrointestinal bleed suspicion)
- A – Anemia (Hemoglobin ≤ 90 g/L)
- C – Chest pain associated with syncope
- E – ECG showing Q-wave (not in lead III)
- S – Saturation ≤ 94% on room air
Each of these markers has strong predictive value for identifying patients at risk of death or serious adverse events.
Detailed Explanation of Each Criterion
1. BNP Level ≥ 300 pg/ml
B-type Natriuretic Peptide (BNP) is a cardiac biomarker secreted when the heart is under stress, especially in conditions like heart failure and ventricular dysfunction. Elevated BNP in a patient presenting with syncope suggests underlying cardiac compromise, which carries a higher risk of morbidity and mortality.
BNP testing is widely available and serves as an objective marker. Patients with BNP ≥ 300 pg/ml should not be discharged without careful evaluation.
2. Bradycardia ≤ 50 bpm
A heart rate of ≤ 50 beats per minute (excluding well-conditioned athletes) is concerning in the context of syncope. Severe bradycardia may indicate sinus node dysfunction, high-grade AV block, or medication-induced conduction abnormalities.
When syncope is associated with bradycardia, the risk of sudden cardiac arrest rises significantly. Monitoring, admission, and possible pacing evaluation are warranted.
3. Rectal Examination Showing Fecal Occult Blood
Syncope may sometimes result from hypovolemia secondary to gastrointestinal bleeding. A positive rectal exam or occult blood detection indicates potential acute GI hemorrhage, which can rapidly destabilize the patient.
This criterion emphasizes the importance of performing a targeted physical examination in unexplained syncope cases.
4. Anemia (Hemoglobin ≤ 90 g/L)
Low hemoglobin levels suggest chronic disease, acute blood loss, or nutritional deficiencies. Severe anemia impairs oxygen delivery, leading to cerebral hypoperfusion and syncope.
Patients with Hb ≤ 90 g/L are at increased risk of collapse, poor outcomes, and complications, making hospital admission crucial.
5. Chest Pain Associated with Syncope
Chest pain with syncope raises the red flag of acute coronary syndrome (ACS), pulmonary embolism, or aortic dissection. These are immediately life-threatening conditions.
Any patient with this presentation requires urgent cardiology or emergency work-up, including troponin testing, echocardiography, and CT imaging when indicated.
6. ECG Showing Q-Wave (Not in Lead III)
ECG remains one of the most valuable tools in syncope evaluation. Pathological Q-waves (excluding lead III) suggest previous myocardial infarction and structural heart disease. Such patients are prone to ventricular arrhythmias, a major cause of sudden cardiac death.
Early identification of ECG abnormalities allows cardiology referral and monitoring.
7. Saturation ≤ 94% on Room Air
Low oxygen saturation may indicate underlying pulmonary disease, pulmonary embolism, pneumonia, or cardiogenic causes. When syncope is accompanied by hypoxemia, hospital admission is necessary for stabilization and oxygen therapy.
Why the ROSE Rule Matters
The ROSE Rule helps physicians in emergency triage and decision-making. Instead of subjective clinical judgment alone, it provides evidence-based guidance to reduce the risk of prematurely discharging high-risk patients.
Studies have shown that the rule has a high negative predictive value, meaning that patients without any BRACES criteria are at relatively low risk of adverse outcomes.
Comparing the ROSE Rule with Other Syncope Tools
Several other rules exist, such as:
- San Francisco Syncope Rule (SFSR) – based on history, ECG, shortness of breath, hematocrit, and systolic blood pressure.
- Canadian Syncope Risk Score (CSRS) – a more detailed scoring system incorporating clinical features, troponins, and ECG changes.
The ROSE Rule differs in its simplicity and strong predictive markers. It is particularly suited for quick decisions in the ED, especially in resource-limited settings.
Clinical Application and Case Scenarios
Case 1: A 72-year-old man presents with syncope. His hemoglobin is 85 g/L. Even though vitals are stable, the ROSE Rule (A – Anemia) indicates admission.
Case 2: A 60-year-old woman collapses, but her ECG shows Q-waves in multiple leads. According to ROSE Rule (E – ECG abnormality), admission is warranted.
Case 3: A young patient faints after prolonged standing with no abnormal findings. No BRACES criteria are met, so safe discharge with outpatient follow-up is reasonable.
Quick Reference Table
| BRACES Mnemonic | Clinical Feature | Admission Trigger |
|---|---|---|
| B | BNP ≥ 300 pg/ml | Suggests cardiac dysfunction |
| B | Bradycardia ≤ 50 bpm | Risk of arrhythmia/sudden arrest |
| R | Rectal exam positive for occult blood | GI bleeding suspicion |
| A | Anemia (Hb ≤ 90 g/L) | Poor oxygen delivery, collapse risk |
| C | Chest pain with syncope | ACS, PE, dissection risk |
| E | ECG showing Q-wave (not in III) | Underlying MI/arrhythmia risk |
| S | Saturation ≤ 94% | Hypoxemia, cardiopulmonary cause |
Frequently Asked Questions (FAQ)
1. What does the ROSE Rule stand for?
It is the Risk Stratification of Syncope in the Emergency Department Rule, used to identify which patients need admission.
2. Is the ROSE Rule better than the San Francisco Syncope Rule?
Both are useful, but the ROSE Rule is simpler and relies on clear laboratory and ECG criteria, making it highly practical in emergency settings.
3. Can patients be discharged if none of the BRACES criteria are present?
Yes, if there are no other concerning features. However, clinical judgment should always be applied.
4. Is BNP always measured in syncope evaluation?
Not always, but it is recommended if cardiac causes are suspected. A BNP ≥ 300 pg/ml is a strong admission indicator.
5. Why is Q-wave in lead III excluded?
Q-waves in lead III can be a normal variant, so only pathological Q-waves in other leads are considered significant.
6. Who should apply the ROSE Rule?
Emergency physicians, internists, and clinicians handling syncope cases should use it as a guide.
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