Is hospitalization needed for patients in whom an underlying cause of syncope is not detected in the Emergency Department (ED)? To answer this question, we conducted a prospective, short-term outcomes study of consecutive patients > or = 50 years old presenting to our ED after a syncopal episode. All subjects received a structured ED evaluation. Forty-five patients met inclusion criteria, 67% were hospitalized. None of the patients experienced a life-threatening event or required significant therapeutic interventions during the hospitalization. No patient had a new diagnosis relevant to syncope. Follow-up interviews 1 month later revealed no repeat ED visits, hospitalizations, or deaths (95% upper CI, 6.5%). One patient reported a recurrent syncope (recurrence 2.2% [95% upper CI, 10%]). This pilot study suggests that a negative structured ED evaluation may identify patients > or = 50 years of age who may be safely discharged from the ED. Further validation is required before this observation is applied to clinical practice.