- Design
- Multicentre, open-label randomised trial
- Population
- 2,234 adults with unexplained syncope after ED assessment, 45 UK hospitals
- Primary outcome
- Mean patient-reported syncope episodes at 1 year
- Effect
- 1.37 vs 1.58; IRR 0.89 (95% CI 0.68 to 1.18)
ASPIRED, an open-label randomised trial in the New England Journal of Medicine (August 2026), enrolled 2,234 adults at 45 UK hospitals whose syncope remained unexplained after emergency department assessment (mean age 58). Half had immediate 14-day ambulatory ECG monitoring; half had standard local care.
At one year, mean patient-reported syncope episodes were 1.37 with monitoring and 1.58 with standard care (incidence rate ratio 0.89, 95% CI 0.68 to 1.18). Adverse events were reported 49 times in the monitoring group against 8, with one serious event in each group.
The primary outcome was recurrence, not diagnostic yield, so monitoring may still find arrhythmias in some patients; and 12% were lost from the primary analysis. The trial enrolled unselected unexplained syncope rather than those with high-risk features.
What changes is the default: a normal ED work-up followed by routine extended monitoring for everyone did not reduce further episodes. Monitoring belongs to patients with red flags for arrhythmia.
- Do not order routine 14-day ECG monitoring for every patient with unexplained syncope
- Reserve extended monitoring for patients with arrhythmic red flags or an abnormal ECG
- Discharge low-risk patients with a clear plan and advice on when to return
- Document the risk features you looked for, whether or not you order monitoring
- Warn patients that monitors bring minor adverse effects
Why it matters
It removes a common default from the ED syncope pathway and frees monitoring for the patients most likely to benefit.
Don't overread it
The trial measured recurrence, not diagnosis, and did not test targeted monitoring in high-risk patients.
The statistics, in plain English
An incidence rate ratio of 0.89 with an interval from 0.68 to 1.18 includes no difference: monitoring might reduce episodes by up to a third or increase them by nearly a fifth. The large standard deviations (5.1 and 8.6) show a few patients with many episodes drove the averages.
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