ROSE Rule Syncope Calculator

How to Use This Calculator

1. Select Yes/No for each of the 7 ROSE criteria based on the patient's presentation and test results.
2. Any single "Yes" = HIGH RISK — admission recommended.
3. All "No" = LOW RISK — discharge may be appropriate with return precautions.
4. Use extended tabs to review rule performance and outcome risk by criterion.

Formula

Example

Frequently Asked Questions

• What is the ROSE rule for syncope and what does it measure? ▼
  The ROSE (Risk Stratification of Syncope in the Emergency Department) rule is a validated clinical decision tool developed to identify patients with syncope who are at high risk for a serious adverse outcome within 30 days. Derived and prospectively validated by Reed et al. and published in Annals of Emergency Medicine in 2010, it evaluates seven binary criteria: BNP 50 pg/mL or greater, bradycardia on EKG less than 50 bpm, positive fecal occult blood test, anemia with hemoglobin less than 90 g/L, chest pain associated with the syncopal episode, oxygen saturation less than 94% on room air, and QRS duration greater than 120 ms on EKG. If any single criterion is positive, the patient is classified as high risk. Serious outcomes include death, arrhythmia, myocardial infarction, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, and any cause requiring intervention. The tool helps emergency physicians decide who requires admission versus who can safely be discharged. Unlike some competing rules, ROSE explicitly incorporates BNP as a biomarker, substantially improving sensitivity for cardiac causes of syncope not apparent from history, EKG, or physical examination alone.
• What is the sensitivity and specificity of the ROSE rule? ▼
  In the prospective validation study by Reed et al. published in 2010 in Annals of Emergency Medicine, the ROSE rule demonstrated a sensitivity of 87% and specificity of 66% for serious adverse outcomes within 30 days. The negative predictive value was 99.2%, meaning that when all seven criteria are negative, there is a very high probability the patient will not suffer a serious outcome within 30 days — making it highly effective as a rule-out tool. The area under the ROC curve was 0.85, indicating good discriminative ability. Compared to the San Francisco Syncope Rule, which showed sensitivity ranging from 74% to 98% across different validation cohorts, ROSE performs comparably but with greater consistency across centers. The biomarker BNP contributes substantially to ROSE sensitivity for cardiac causes, capturing heart failure, severe valvular disease, and myocardial dysfunction-related syncope that purely history- and EKG-based rules might miss. Clinical decision tools are designed to supplement, not replace, clinical judgment — high clinical suspicion for a dangerous cause should prompt admission regardless of score.
• Why is BNP included in the ROSE rule? ▼
  Brain natriuretic peptide (BNP) is a cardiac biomarker released by ventricular myocytes in response to increased wall stress, volume overload, or myocardial ischemia. Its inclusion in the ROSE rule reflects its strong predictive value for identifying cardiac causes of syncope not immediately apparent from history, physical exam, or EKG. Heart failure, severe valvular disease (especially aortic stenosis), and pulmonary hypertension are all associated with elevated BNP even before other clinical signs become obvious. Reed et al. found BNP 50 pg/mL or greater to be one of the most powerful individual predictors of serious outcome among all tested variables. The 50 pg/mL threshold was chosen to maximize sensitivity while maintaining clinical utility; it is intentionally lower than the diagnostic threshold for heart failure, which is typically 100 pg/mL or greater. Clinicians should note that BNP can be elevated in renal failure, sepsis, and other non-cardiac conditions, so results must always be interpreted in the full clinical context. BNP is now routine in most emergency departments, making ROSE practical at the bedside without requiring special testing infrastructure beyond standard ED capabilities.
• How does the ROSE rule compare to the San Francisco Syncope Rule and CANADIAN score? ▼
  Multiple syncope risk stratification tools have been developed and compared in the emergency department setting. The San Francisco Syncope Rule uses five variables: abnormal EKG, shortness of breath, systolic blood pressure less than 90 mmHg, hematocrit less than 30%, and history of congestive heart failure. While it showed high sensitivity in its derivation study, external validation produced highly variable results with sensitivity ranging from 74% to 98%, limiting its reliability across centers. The CANADIAN Syncope Risk Score is a nine-variable numeric scoring system stratifying patients into low, medium, and high risk, with an AUC of approximately 0.87 in both derivation and external validation cohorts. ROSE uses a simpler binary framework where any single positive criterion equals high risk. Studies comparing these tools show ROSE and CANADIAN generally outperform the San Francisco rule in cross-center consistency. ROSE uniquely incorporates BNP, capturing cardiac failure causes that other rules may miss. The European Society of Cardiology 2018 syncope guidelines recommend structured initial risk stratification for all syncope patients, but no single rule has been universally mandated — clinical practice typically combines rule-based approaches with clinical judgment, particularly when structural heart disease or family history of sudden cardiac death is present.
• Which syncope patients can safely be discharged from the ED? ▼
  Safe discharge of a syncope patient requires both negative risk stratification and absence of high-risk clinical features. Patients who are ROSE-negative — all 7 criteria absent — have a serious 30-day outcome risk of less than 1% based on available evidence and can generally be considered for discharge with appropriate precautions. However, certain features independently warrant admission regardless of ROSE: known structural heart disease such as hypertrophic cardiomyopathy, severe aortic stenosis, or prior myocardial infarction; family history of sudden cardiac death in a first-degree relative under age 40; syncope during exertion; syncope in the supine position; new or previously undiagnosed EKG abnormalities including complete heart block, pre-excitation, prolonged QT, or Brugada pattern; hemodynamic instability at presentation; or multiple recurrent episodes without prior workup. Conversely, young patients with classic vasovagal features including prolonged standing, emotional trigger, prodrome of nausea and diaphoresis, witnessed brief loss of consciousness with rapid full recovery, and a completely normal EKG have very low risk and can be discharged with lifestyle counseling. All patients discharged after syncope must be advised not to drive until formally cleared by a physician, given the legal and safety implications of loss of consciousness while operating a motor vehicle.

Related Calculators