640 The utilisation of a remotely monitored implantable loop recorder as first line investigation in the diagnosis of syncope: The EaSyAS II study

Abstract

Implantable loop recorder (ILR) technology offers the ability for prolonged monitoring of the syncopal patient, allowing the best chance of achieving symptom-rhythm correlation. In our randomised study we compared the immediate use of a remotely monitored ILR in the initial investigation of unexplained syncope, with conventional management in patients with recurrent unexplained syncope. 246 patients (age > 16 years, with ≥ 2 syncopal episodes within 2 years) were recruited over a 16 month period (2007 to 2009) into the Eastbourne Syncope Assessment Study II (EaSyAS II) and were randomised to conventional care alone, conventional care and syncope clinic attendance, ILR alone or ILR plus syncope clinic attendance. Primary outcomes were time to ECG diagnosis and time to institution of ECG directed therapy. Median follow up was 20 months (IQ Range 15-27). 120 patients received the ILR. All implants were undertaken as daycases and there were no implant related complications. A total of 62 ILR patients (50%) achieved ECG diagnosis compared with 1 conventionally managed patient. Mean time to diagnosis was 95.2 das post induction. ILR use resulted in a quicker time to ECG diagnosis and ECG directed therapy (HR 35.54, 95% CI 4.84-261.01, P = 0.0004). All ILR diagnoses were achieved at 1st post induction syncope with no data loss. ILR patients were less likely to experience a 2nd syncope compared to standard care patients (HR 0.38, 95% CI 0.17 - 0.86, P = 0.02). Syncope clinic care was the most cost effective (cost per diagnoses and cost per QALY) followed by ILR use. No benefit appeared to be gained by combining ILR and syncope clinic. Our findings support the hypothesis that a remotely monitored ILR can be used as a safe and cost effective first line investigation in recurrent unexplained syncope. It is associated with an increased diagnostic yield and quicker time to ECG diagnosis when compared to conventional management enabling prompt and appropriate ECG directed therapy. In addition continuous remote monitoring prevents data loss increases diagnostic rate from a spontaneous syncopal event.Tabled 1