Syncope Evaluation at a Crossroad

Syncope is one of the most common, alarming, and challenging symptoms with which cardiologists, and most other physicians, grapple.1 2 It can cause injury and disability, affect lifestyle and quality-of-life, and be an expensive management nightmare.3 4 5 Causes range from isolated, benign, situational, and “dysautonomic” events to life-threatening ventricular arrhythmias.2 6 7 A thoughtful history and complete physical examination, performed by an astute clinician, will provide diagnostic clues to guide management.2 8 9 Unfortunately, the approach often undertaken includes low-yield testing (EEG, CT scan, carotid Dopplers, Holter monitor, and cardiac enzymes),2 4 10 yet even “proper” testing (electrophysiology testing and tilt table testing) can be fruitless. In nearly half of all patients, no diagnosis is secured.2 6 11 Although an implantable loop recorder (ILR) may be useful when all else fails,12 no randomized trial has provided evidence that it is the best initial approach when the history …