Use of an Extended Monitoring Strategy in Patients With Problematic Syncope

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Abstract
Background —The conventional investigation of patients who present with syncope involves short-term ECG monitoring or provocative testing with head-up tilt and electrophysiological testing. A symptom-rhythm correlation is often difficult to obtain during spontaneous syncope because of its sporadic, infrequent, and unpredictable nature. Methods and Results —We used a prolonged monitoring strategy to determine the cause of syncope in 85 patients (age, 59±18 years; 44 men) with recurrent undiagnosed syncope with an implantable loop recorder capable of cardiac monitoring for up to 18 months. During a mean of 10.5±4.0 months of follow-up, symptoms recurred in 58 patients (68%) 71±79 days (2.3±2.6 months) after implantable loop recorder insertion. An arrhythmia was detected in 42% of patients who recorded a rhythm during recurrent symptoms, with bradycardia present in 18 and tachycardia in 3. Five of the 18 bradycardic patients and 2 additional sinus rhythm patients received a clinical diagnosis of neurally mediated syncope. Patients who experienced presyncope were much less likely to record an arrhythmia during symptoms compared with recurrence of syncope (24% versus 70%, P =0.0005). There were no adverse events associated with recurrent symptoms, and there were no sudden deaths. Inability to freeze after an event occurred in 8 patients, and pocket infection occurred in 3. Conclusions —The strategy of prolonged monitoring is effective and safe in patients with problematic syncope.