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Aims To analyse the long-term outcome of the largest reported cohort of patients presenting asystole during head-up tilt test. (80 ) n=198)) influenced the time to the syncopal episode (13 (6·5, 20·5) vs 2 (1, 6·5) min, P=0,0005) but not the duration of the asystole. During this period, therapy for asystole featured three different stages: first patients were treated with pacemakers; later drug therapy (metoprolol and/or etilefrine) was recommended; lastly (from 1995), no specific treatment was given. In a cohort age-and gender-matched study, those patients without were compared to those with asystole in a 2:1 basis. During 40·7 months of follow-up (17·7, 66·8), 12 patients (20·6%) with asystole had syncopal recurrences. Furthermore, 34 patients (28·8%) without asystole presented syncopal episodes during a follow-up of 51·6 months (29·3, 73·1) (P=ns). The Kaplan-Meier analysis in patients with and without asystole showed a mean time free of recurrence of 92·6 6 months vs 82·6 4·7 months (P=ns). The previous number of syncopes had a significant relationship with recurrences (P=0·002), but not therapy. There were no cardiac related deaths. Methods and Results Conclusions(1) Asystole during head-up tilt test does not imply a malignant outcome and syncope recurrence is low; (2) pacemaker or drug therapy do not significantly influence outcome which correlates to the previous number of syncopal episodes but not to gender, age, asystole occurrence, asystole duration and timing to asystole during head-up tilt test; (3) tilting protocol (angle) might influence time to and incidence of asystole during head-up tilt test.