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TOPLINE
An external validation study found that the ROMEO score had high sensitivity for predicting a low risk for clinically significant transthoracic echocardiography (TTE) findings in adults who presented to the emergency department (ED) with syncope or presyncope.
METHODOLOGY
- Researchers conducted a secondary analysis of a multicenter, prospective, observational cohort study across one community and five academic EDs in the US between 2020 and 2024 to externally validate the ROMEO score.
- A total of 1287 adults aged 40 years or older who presented to the ED with syncope or presyncope without a serious ED diagnosis were enrolled. Of these, 427 underwent cardiology-performed TTE within 30 days and were included in the analysis.
- The primary outcome was clinically significant TTE findings — including structural and functional cardiac abnormalities associated with syncope — within 30 days.
- Researchers assessed the sensitivity, specificity, positive and negative predictive values, and area under the curve (AUC) of the ROMEO score, which incorporates five predictors — a history of heart failure, a history of coronary artery disease, an abnormal ED electrocardiogram, elevated high-sensitivity troponin T levels, and elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels.
TAKEAWAY
- Among the patients who underwent TTE, 20.6% had at least one clinically significant finding. Reduced left ventricular ejection fraction (< 45%) was the most common abnormality (12%), followed by regional wall motion abnormalities (6%). Men were more likely than women to have clinically significant TTE findings (66% vs 34%; P < .001).
- A ROMEO score of 0 demonstrated a sensitivity of 98.9% and a negative predictive value of 98.6% for excluding clinically significant TTE findings. The specificity and positive predictive value were 20.2% and 24.3%, respectively. The AUC was 0.830 (95% CI, 0.787-0.874).
- Patients with a ROMEO score of 0 had a 1.4% probability of having clinically significant findings on TTE. Among the ROMEO score components, a history of heart failure showed the strongest association with clinically significant TTE findings (adjusted odds ratio, 3.78; P < .001).
- Patients with clinically significant TTE findings had higher median NT-proBNP levels (802.6 pg/mL vs 125.8 pg/mL; P < .001) and high-sensitivity troponin T levels (22.3 ng/L vs 10.4 ng/L; P < .001) than those with normal or minor TTE findings.
IN PRACTICE
"The ROMEO score can reliably identify a cohort of patients who are at very low risk of clinically significant findings on TTE and could help reduce low-yield testing. Future research could explore how this score could be implemented into clinical practice, particularly in an ED or observation unit setting, to optimize resource utilization," the authors of the study wrote.
SOURCE
The study was led by John DeAngelis, University of Rochester, Rochester, New York. It was published online on June 24, 2026, in the Academic Emergency Medicine.
LIMITATIONS
The study was limited by potential selection bias due to the nonenrollment of screened patients, limited generalizability because most participants were recruited from urban academic centers, and verification bias because TTE was not performed for all enrolled patients.
DISCLOSURES
The study was funded by the National Heart, Lung, and Blood Institute, National Institutes of Health. No relevant conflicts of interest were reported.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
