Despite the development of guidelines based on the best available scientific evidence, the dissemination of these concepts into clinical practice remains a challenge. Educating every physician who is likely to be involved in the care of patients presenting with syncope is virtually impossible. As a result, we see inappropriate use of diagnostic tests, a high number of patients with misdiagnoses or without a diagnosis, and excessive use of health care resources. Indeed, several studies have shown great interhospital and interdepartmental heterogeneity regarding the incidence of emergency admissions, in-hospital diagnostic pathways, and rate of diagnosis (2,31- 37). For example, in the EGSYS 1 trial (31) including 996 consecutive patients who presented to the ED with syncope, carotid sinus massage and head-up tilt tests were performed in 0% to 58% and 0% to 50% of the patients, respectively. Prolonged ECG monitoring was performed in 3% to 90% of patients. Consequently, the final diagnosis of reflex-mediated syncope ranged from 10% to 79%. In a recent study performed at the University of Utah (38), we also found important discrepancies between clinical practice and the recommended guidelines. In some instances, tests were performed in the absence of clear indications, and conversely in other instances, many tests should have been performed and were not; 36% of admissions did not meet the indications suggested by the ESC guidelines, and 38% of the final diagnoses were not sufficiently supported.