Design: Open-label randomised controlled trial, 45 hospitals
Population: 2234 adults with syncope unexplained after emergency department evaluation, UK
Primary outcome: Patient-reported syncope episodes at 1 year
Effect: 1.37 vs 1.58 episodes, incidence rate ratio 0.89 (95% CI 0.68–1.18)

ASPIRED randomised 2234 adults whose syncope remained unexplained after emergency department assessment, at 45 UK hospitals. One group received 14-day ambulatory ECG monitoring straight away; the other received each site's standard care. The primary outcome was patient-reported syncope episodes at one year.

The mean number of episodes was 1.37 with monitoring and 1.58 with standard care, not a significant difference. Adverse events, mostly minor, were more common with monitoring (49 against 8).

The trial tested whether early monitoring prevents further syncope, and it did not. That does not make monitoring useless for diagnosis in patients with red flags such as exertional syncope, palpitations, structural heart disease or an abnormal ECG. It argues against routine early monitoring for every patient with unexplained syncope as a way of preventing recurrence.

Do not order routine two-week monitoring for all unexplained syncope expecting fewer recurrences
Target monitoring at red flags: exertional syncope, palpitations, structural heart disease, abnormal ECG, family history of sudden death
Take a careful history and 12-lead ECG, which remain the highest-yield tests
Tell patients what to do if syncope recurs

Why it matters

It questions the reflex to monitor every unexplained faint when monitoring does not change what happens next.

The statistics, in plain English

An incidence rate ratio of 0.89 (95% CI 0.68–1.18) crosses 1, so no reduction in episodes was shown; the interval allows anything from a 32% reduction to an 18% increase. The very large standard deviations show most patients had few or no episodes while a few had many.