Since their publication in 2000, the Newcastle protocols1 on head-up tilt testing in the diagnosis of vasovagal syncope and related disorders have provided a succinct and practical guide for those setting up and managing syncope services incorporating the investigation and management of neurally mediated disorders. In the intervening seven years our protocols have changed in line with published evidence on new methodologies and management strategies and our own clinical experience (with more than 1000 new and 3000 review patients seen each year at our specialist syncope facility), so the time is ripe for a fresh approach. Much of this information is available in a number of important papers on syncope management2^–4 and pacing indications5 6; while comprehensive, these guidelines are also lengthy and inclusive of competing methodologies. They are therefore less accessible for those needing a more prescriptive and pragmatic view. The Newcastle protocols 2008 presented below provide such a view. Since these protocols reflect current clinical practice, an exhaustive review of the evidence base for the various methodologies presented will not be attempted—the reader should consult the more detailed papers referenced if this is required.2^–6 Similarly some prior knowledge of the subject matter is assumed, in particular the differentiation between syncope and non-syncopal loss of consciousness as well as the diagnostic process leading to head-up tilt table testing.2 3 The protocols are designed for adults with syncope (defined as transient loss of consciousness with loss of postural tone and spontaneous and complete recovery), with no upper limit on age.

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The Newcastle protocols 2008 are intended to complement rather than reproduce the originals, so only new information will be presented, occasionally with a summarised version of the old to aid clarity. Still-valid detailed prior information will be referenced to the …