The renewed 2018 syncope guidelines published by the European Society of Cardiology (ESC) reiterate that the initial evaluation of syncope should include history taking, physical examination, an electrocardiogram, and orthostatic blood pressure measurements (OBPM). However, the importance of evaluating for orthostatic hypotension (OH) often remains underappreciated in clinical practice. In this study, we examine the initial evaluation of syncope on an ED. We retrospectively reviewed 2 years of consecutive medical records of patients presenting with a syncope to the ED of a university hospital. We collected patient demographics and data on initial syncope evaluation for further analysis. In a cohort of 289 patients, OBPM and ECG were performed in 16 and 89% of the cases, respectively. An OBPM was performed in only 52% of the patients who received a working diagnosis of OH. In the other 48%, the OH diagnosis was likely made on the basis of history taking and exclusion of other syncope causes. OBPM are infrequently used during the initial evaluation of syncope irrespective of its consistent inclusion in ESC syncope guidelines. The discordance between clinical practice and the ESC syncope guidelines calls for increased awareness of the role of OBPM in the initial evaluation of syncope by either stricter guideline adherence or reappraisal of clinical practice.