Key result
Upfront pacing cuts major events ~46% at 1 year versus standard care.
Why the trial?
In older patients with high-risk unexplained syncope, bradyarrhythmia is a frequent culprit that standard stepwise workup may identify only after recurrent injury. Syncope-Stopper asked whether upfront pacing reduces recurrence compared with standard care.
Does upfront pacing reduce the composite of recurrent syncope, bradycardia requiring pacemaker, cardiovascular death and device-related complications in high-risk patients aged 55 or older with unexplained syncope?
Population
Adults >=55 years with unexplained syncope in the past year and DROP score >=2
Comparison
Upfront pacemaker implantation vs standard care
Design
Randomized trial; sample size, blinding and centre details not reported
Follow-up
1 year
Authors
No takes yet. Share an insight, caveat, or question.
Captured external expert commentary on this trial, strongest first. Original sources are linked where available.
Syncope-Stopper evaluated upfront pacing versus standard care in high-risk patients (age ≥55, DROP score ≥2) with unexplained syncope but no documented bradycardia. The primary composite endpoint of recurrent syncope, bradycardia requiring pacemaker, cardiovascular death, and device-related complications at 1 year was significantly reduced with upfront pacing (17.2% vs 31.7%; p=0.014). The trial was presented in Hot Line 10 at ESC Congress 2026.
“HOTLINE Should we implant a pacemaker before documenting bradycardia in selected patients with high risk unexplained syncope? The Syncope Stopper randomized trial, presented at #ESCCongress, tested exactly this strategy. Two hundred predominantly elderly patients with”
Supports upfront pacing in high-risk unexplained syncope; extends randomized evidence to patients without documented bradycardia.
| Outcome | Pacing | Standard |
|---|---|---|
| Recurrent syncope, bradycardia requiring pacemaker, CV death, or device complication | 17.2% | 31.7% |
| Primary composite at 1 year · p=0.014; component breakdown not reported | ||
Statistical certainty
Sample size, confidence interval and component-level results are not reported, and follow-up is limited to 1 year.
Design limitations
The composite includes 'bradycardia requiring pacemaker', an event that by design accrues mainly in the standard-care arm.
Patient burden
Device-related complications are folded into the primary composite and not reported separately.
Does upfront pacing reduce the composite of recurrent syncope, bradycardia requiring pacemaker, cardiovascular death and device-related complications in high-risk patients aged 55 or older with unexplained syncope?
Absolute Event Rate: 17.2% vs 31.7%
p-value: p=0.014
Upfront pacing significantly reduces adverse clinical outcomes at 1 year in high-risk older patients with unexplained syncope compared to standard care.
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Jeremy William (2026) conducted an RCT in high-risk unexplained syncope. Upfront pacing vs. standard care was evaluated on recurrent syncope, bradycardia requiring pacemaker, cardiovascular death and device-related complications at 1 year (p=0.014). Upfront pacing significantly reduced recurrent syncope, bradycardia requiring pacemaker, cardiovascular death, and device-related complications at 1 year versus standard care (17.2% vs 31.7%; p=0.014).
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