83 y/o caucasian male, healthy, but with rheumatoid arthritis under treatment has experienced 1 syncopal episode and 18 near syncopal episodes since July, 2009, averaging about 1-2/month. The episodes are all very similar and (depending on severity), include, dizziness, changes in visual acuity, inability to stand or walk, nausea and retching, and weakness. There are no prodromal symptoms but the patient takes a few minutes to fully recover from the sequelae of an attack. Has received complete cardiac workup with duplex carotid ultrasound, cardiac echo, nuclear scan, Tilt table, holter monitoring x 30 days, and otolaryngologic evaluation---all negative. The only clues were obtained by myself (as nephew). In April, 2009, while driving, the patient suffered an attack and had to pull to the curbside. Within several seconds, I touched his radial pulse from the rear seat of the vehicle and noticed a tachycardia. On 16 July just subsequent to an attack, his systolic blood pressure was measured at 200mm Hg. In addition, subsequent to this same attack, (4) 20-second episodes were recorded by Holter and sent to a monitoring center via telephone. These were apparently unremarkable. The possibility is suspected that an brief brady or tachyarrhythmia is responsible for all of these episodes and has gone unrecorded by the Holter due to the fact that the arrhythmia is so very brief that it has terminated by the time that the patient experiences (and reacts to) the symptoms. There are no identified blood sugar abnormalities, or seizure disorders. There is no history of hypertension or clotting disorders. There is a family risk factor for atherosclerotic heart disease. What is needed is guidance on choosing the next appropriate step--perhaps an implantable loop recorder in Cleveland, Ohio?