Having read the position paper on diagnosing syncope [1], I question the advice given for the use of 24-hour Holter monitoring as opposed to long-term ambulatory loop electrocardiography (30-day event monitoring). According to the data presented in this article, it is clear that the overall diagnostic yield of loop recording far exceeds that of 24-hour Holter monitoring (24% to 47% compared with 19%). The value of this increased diagnostic yield of loop recording far outweighs the diagnostic yield of 14% for asymptomatic arrhythmia seen on 24-hour Holter monitoring.

I believe that loop recording should replace 24-hour Holter monitoring as the outpatient monitoring test of choice in patients with organic heart disease (branch 1 of the Figure in the position paper) as well as in those without suspected heart disease. The article also states that in patients with a high pretest probability of arrhythmia and a negative result on 24-hour Holter monitoring, further evaluation for arrhythmia should be pursued by event monitoring or electrophysiologic study. Why not do the event monitoring initially?

The authors also state that loop recording is most beneficial in patients with frequent episodes of syncope. Because loop recording is usually done for 30 days, it seems that this would be a much better method for diagnosing infrequent syncope than 24-hour Holter monitoring.

This article confirms my experience that for the diagnosis of syncope in a compliant patient not requiring in-patient monitoring, 30-day event recording is a much better and more cost-effective test than 24-hour Holter monitoring.