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(Circulation. 2001;104:7.)
© 2001 American Heart Association, Inc.

Editorials

Syncope Evaluation at a Crossroad

For Which Patients?

Brian Olshansky, MD

From the Division of Cardiology, University of Iowa Hospital, Iowa City.

Correspondence to Brian Olshansky, MD, Division of Cardiology, University of Iowa Hospital, 200 Hawkins Drive, 4426 B, JCP, Iowa City, IA 52242-1081. E-mail brian-olshansky@uiowa.edu

Key Words: Editorials • syncope • diagnosis

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 does not provide a diagnosis ... until now.

Krahn et al¹³ report the first prospective, randomized trial of the ILR as the initial approach when the cause for syncope could not be gleaned from a circumspect evaluation. They address an important clinical problem and provide new insight into methods to assess syncope. The best way to identify the cause is to monitor the episode. The ILR can do just that: it can provide a diagnosis efficiently, apparently safely, and correctly, but this approach does not yet revolutionize syncope management.

Patient selection criteria are crucial. The study impact depends on who is enrolled, but this criterion remains obscure; those included were referred and selected. . . . [Full Text of this Article]

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				C. C. Kurer Implantable looprecorders: dollars and sense J. Am. Coll. Cardiol., August 6, 2003; 42(3): 502 - 504. [Full Text] [PDF]

				W. M. Landau, A. D. Krahn, G. J. Klein, R. Yee, and A. C. Skanes Randomized Assessment of Syncope Trial: Conventional Diagnostic Testing Versus a Prolonged Monitoring Strategy * Response Circulation, March 12, 2002; 105 (10): e61 - e61. [Full Text] [PDF]