ASPIRED: 14-day ECG monitoring did not reduce syncope episodes after unexplained ED syncope

Design

Open-label, multicentre randomised controlled trial

Population

2,234 adults with unexplained syncope after ED evaluation, 45 UK hospitals

Primary outcome

Patient-reported syncope episodes at 1 year

Effect

1.37 vs 1.58 episodes; IRR 0.89 (95% CI 0.68 to 1.18)

The ASPIRED trial, published in NEJM on 31 August 2026, randomised 2,234 adults whose syncope remained unexplained after emergency department assessment, across 45 UK hospitals, to 14-day ambulatory ECG monitoring or each site's standard care. Mean age was 58.

In the 1,970 patients analysed, the mean number of patient-reported syncope episodes at one year was 1.37 with monitoring and 1.58 with standard care (incidence rate ratio 0.89, 95% CI 0.68 to 1.18; P = 0.42). Adverse events, mostly minor and device-related, were more frequent with monitoring.

The trial tested whether early monitoring reduces recurrence, not whether it finds arrhythmias. Ambulatory monitoring remains useful for selected patients with features suggesting an arrhythmic cause, but routine immediate monitoring of all unexplained syncope did not change outcomes.

• Do not order 14-day ambulatory ECG routinely for every patient with unexplained syncope.
• Target monitoring at patients with high-risk features: exertional syncope, palpitations, abnormal ECG, structural heart disease or family history of sudden death.
• Use a validated syncope risk tool to guide admission and follow-up.
• Arrange outpatient review for unexplained syncope rather than defaulting to monitoring.

Why it matters

Routine monitoring uses devices and clinic time without reducing recurrence.

Don't overread it

The endpoint was syncope recurrence; the trial does not show monitoring is useless for arrhythmia diagnosis.

The statistics, in plain English

An incidence rate ratio of 0.89 with an interval of 0.68 to 1.18 includes both a modest reduction and a modest increase, so no benefit was shown.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.