Study objective: Emergency department (ED) visits for syncope are common and routine diagnostic testing is frequently low yield. Our objective is to determine whether recent guidelines emphasizing limiting hospitalization and advanced diagnostic testing to high-risk patients have changed patterns of syncope care. Methods: This was a retrospective population epidemiology study of syncope-related ED visits and hospitalizations using the National Emergency Department Sample from 2006 to 2014 and the State Inpatient Databases and Emergency Department Databases from 2009 and 2013. Primary outcomes were annual incidence rates of syncope ED visits and subsequent hospitalizations, and rates of hospitalization, observation, 30-day revisits, and diagnostic testing comparing 2009 with 2013. Differences were estimated with multivariable logistic regression modeling adjusted for patient clinical and demographic characteristics. Results: From 2006 to 2014, we identified 15,154,920 survey-weighted ED visits for syncope. Annual rates of ED visits increased from 643 to 771 per 100,000 adults, whereas hospitalizations declined from 36.3% to 24.7% (–11.6% absolute difference; 95% confidence interval [CI] –13.0% to –10.2%). In multistate adjusted analyses, the proportion of ED visits resulting in hospital admission decreased 11.7% (95% CI –11.9% to –11.6%) between 2009 and 2013, whereas the proportion of ED visits resulting in observation care increased by 7.9% (95% CI 7.8% to 8.0%), with no significant change in 30-day ED revisit rates (absolute difference 0.1%; 95% CI –0.1% to 0.3%). The frequency of advanced cardiac testing increased from 13.8% to 17.0%, and neuroimaging increased from 40.6% to 44.3%, driven by increased testing of patients receiving observation and inpatient care. Conclusion: Although the incidence of ED visits for syncope has increased, hospitalization rates have declined, without an adverse effect on ED revisits, possibly because of increased use of observation care. Use of advanced cardiac testing and neuroimaging has increased, driven by growth in testing of patients receiving observation and inpatient care.