The patient was equipped with a loop monitor. The strip below is part of the five minute strip. This is an interesting case of recurrent syncope the cause of which was finally diagnosed with prolonged loop monitoring. The flutter waves are best seen after the last QRS before the period of asystole. The answer is partly that the patient was symptomatic because there was no escape ventricular rhythm.
Confusion tends to indicate that syncope is neurologic.
In this case the patient was confused and it was his partner that pushed the event button. Prolonged asystole can cause confusion and limits the usefulness of patient loop recorders, and confusion does not rule out a cardiac arrhythmia. P.O. B.I.D. with resolution of his symptoms.