Underuse of Implantable Loop Recorders in Elderly Patients with Syncope and Unexplained Falls

Background: Implantable loop recorders (ILRs) may improve detection of cardiac causes of syncope. Their use in elderly patients is not clear.

Methods: Observational study including patients ≥65 years with unexplained syncope and/or falls undergoing cardiac evaluation, comparing patients with and without cardiac causes on baseline characteristics, indications for pacemaker/ILR, and mortality (mean follow-up ≥1 year). All electrocardiograms (ECGS) were retrospectively re-evaluated.

Results: 374 of a total of 419 patients (mean age 80, SD 6 years) underwent cardiac evaluation. 121 patients had a proven/suspected cardiac cause for the syncope/fall. Ten patients underwent pacemaker/ICD and twelve patients ILR implantation, leading to a diagnosis in five. Sixty patients were advised to undergo ILR implantation after a next event; only three received an ILR during follow-up, although eleven experienced symptoms. Within the group of patients that underwent a cardiac evaluation, there was a higher mortality rate in the cardiac group versus the other causes group (p=0.03). The cardiac group had significantly more ECG abnormalities. Also patients with a cardiac evaluation had more ECG abnormalities (p=0.02). Based on the initial ECG, respectively 9 and 72 patients with a cardiac evaluation had an indication for pacemaker and ILR, but only five patients received a pacemaker and five patients received an ILR. Nine patients without cardiac evaluation (20%) had an indication for ILR based on their ECG.

Conclusions: A substantial number of elderly syncope and fall patients had ECG abnormalities suggestive of a cardiac cause, with an indication for ILR/pacemaker implantation, but only a small number received a device. A cardiac evaluation and early ILR implantation should be considered more often in the diagnostic work-up of unexplained syncope and falls in the elderly.