Fourteen-day ECG monitoring after unexplained syncope did not reduce further syncope at a year

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. Half had a 14-day ambulatory ECG patch immediately; half had the usual local care.

The mean number of patient-reported syncope episodes at one year was 1.37 against 1.58 (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.

The primary outcome was recurrence, not diagnosis, and a monitor can find an arrhythmia without reducing episodes if most recurrences are reflex syncope. About 12% had no follow-up and were excluded from the primary analysis.

For most patients the history and ECG remain the investigation that matters; extended monitoring belongs to those with features suggesting an arrhythmic cause.

• Take a careful history of the prodrome, posture and triggers — most syncope is reflex
• Reserve extended ECG monitoring for red flags: exertional syncope, syncope while supine, palpitations first, or an abnormal ECG
• Do not order routine 14-day monitoring for every unexplained faint
• Tell patients that monitoring brought more minor adverse events than standard care

Why it matters

It questions the reflex to monitor everyone after an unexplained faint, a common and resource-heavy default.

Don't overread it

The trial measured recurrence, not diagnostic yield, and did not test targeted monitoring in high-risk patients.

The statistics, in plain English

An incidence rate ratio of 0.89 suggests 11% fewer episodes, but the interval from 0.68 to 1.18 includes no difference, and the large standard deviations mean a few patients with many episodes drove the averages.

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.