Decision pathway for cardiac pacing in patients with reflex syncope. DDD = dual-chamber, atrioventricular pacing. Note: cardioinhibitory carotid sinus syndrome is defined when the spontaneous syncope is reproduced by the carotid sinus massage in the presence of an asystolic pause >3 s; asystolic tilt positive test is defined when the spontaneous syncope is reproduced in the presence of an asystolic pause >3 s. A symptomatic asystolic pause(s) >3 s or asymptomatic pause(s) >6 s due to sinus arrest, atrioventricular block, or the combination of the two similarly define asystole detected by implantable loop recorder. Figure adapted from Brignole et al.⁶²