International Circulation:  The new guideline suggests that early use of an implantable loop recorder might become the reference standard to be adopted when an arrhythmic cause of syncope is suspected but not sufficiently proven to allow treatment based on etiology. Which kinds of patients do you think will benefit most from an ILR as the first line diagnostic strategy?

Win-Kuang Shen:  The opinions vary a lot even though there are some general guidelines about rhythm in the most recent version.  It really comes down to the physician’s capability of evaluating patients depending on the degree of suspicion and determining if the patient has a cardiogenic cause of syncope or a non-cardiogenic cause.  To me it is really， as always， that the clinical decision is important in that the physician’s capability of taking an accurate history and other parts of the evaluation are important.  When I evaluate syncope I try to divide the patients into three categories of prognosis， the patients with very low risk， intermediate， or high risk for cardiac cause of syncope.  Once you’ve completed the initial evaluation and are still unable to establish a diagnosis then that is the time where an implantable loop recorder will be important， particularly in patients who are in the intermediate risk group.  In the high risk you try very hard to establish a diagnosis before implanting a device.  In the low risk group， if the patients have recurrent， unexplained episodes of syncope then it can be reasonable to consider implanting a loop recorder. 

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