A 78-Year-Old Man Is Evaluated for Syncope

A 78-year-old man is evaluated for syncope.  He was hospitalized a week ago after passing out in his garden and sustaining a minor head injury.  He had no prodromal symptoms, chest pain, or palpitations.  After the syncopal episode, he was not confused and had only a mild headache due to trauma.  Four months ago, the patient had a similar episode at home but sustained no injuries.  He has hypertension, for which he takes lisinopril and amlodipine.  He does not use tobacco, alcohol, or illicit drugs.  He walks 4 miles a day.
Blood pressure is 140/90 mm Hg supine and 138/88 mm Hg standing, and pulse is 75/min and regular.  Fourth heart sound is heard on cardiac auscultation.  There are no carotid bruits.  Carotid sinus massage does not provoke long pauses.
Electrocardiogram shows normal sinus rhythm with tall R waves.  An echocardiogram done in the hospital showed left atrial enlargement, left ventricular hypertrophy, and ejection fraction of 60%.
Which of the following is the best next step in management of this patient?

A) 24-hour electrocardiogram (Holter) monitoring
B) Discontinuation of medications
C) Electroencephalogram
D) Implantable loop recorder
E) Permanent cardiac pacemaker

Correct Answer:

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