Physician Perspectives on the Initial Diagnostic Strategy of Syncope in Older Patients Without Diagnostic Clues

Syncope in adults at least 50 years old without structural or electrical heart disease has numerous potential causes, and uncertainty persists in up to 41% of patients. Guideline-directed investigations include implantable cardiac monitoring (ICM) and tilt table testing (TTT). Physician preferences about which to perform first are unknown. We aimed to understand physician opinions on whether to first utilize ICM or TTT to investigate syncope in older patients without electrical or structural heart disease.

Physicians assessing syncope patients completed an online survey about diagnostic strategy, test availability, and values about test accuracy and clinical consequences.

Seventy-one physicians completed the survey; 77% were cardiac electrophysiologists. Most respondents (62%) felt the optimum first test depended on the clinical scenario, 30% preferred an ICM, and 8% preferred a TTT. Tests were widely available: both tests were present in 76% of sites, TTT alone in 3%, ICM alone in 18%, and neither in 3%. TTT was preferred in Europe (75%) while ICM was preferred in North America (85%; p = 0.024). Concerns about missed diagnoses were expressed about TTT by 61% of physicians and only 19% for ICM. Following a negative first test, physicians were more likely to recommend an ICM (39%) than a TTT (11%), and more likely to watchfully wait after a negative ICM (45%) than a negative TTT (11%; p < 0.001).

International equipoise exists about whether to pursue strategies of first conducting a TTT or implanting an ICM, although opinions differ between physicians practicing in Europe and North America.

ClinicalTrials.gov identifier: NCT05776810.