The management of patients with carotid sinus syndrome: is pacing the answer?

Abstract

Carotid sinus syndrome (CSS) is an under recognized cause of recurrent unexplained syncope and potentially of recurrent falls in the elderly. The mechanisms that lead to syncope in patients with CSS remain debated. However, evidence for both peripheral and central alterations have been recently reported. The diagnosis of CSS is challenging and a high clinical suspicion is usually needed to make the diagnosis. Clinical presentation may be typical and characterized by a clear association between accidental manipulation of the carotid sinus and the presentation of syncope. On the other hand, recurrent unexplained syncope and unexplained falls may be the clinical presentation of patients with CSS without a specific trigger. Carotid sinus hypersensitivity documented by carotid sinus massage (CSM) may be the only finding indicating the possibility of CSS as the cause of syncope. In older patients with recurrent unexplained syncope and a negative diagnostic work-up, carotid sinus massage both in the supine and upright positions is recommended. CSS may present primarily as a cardioinhibitory response or a true vasodepressor response. Therapy should address any underlying pathology if present, and be directed to either prevent cardioinhibition, vasodepression or both alterations. A variety of medical therapies have been used with unclear effects. No appropriately designed controlled clinical trials have been performed comparing pacing with medical therapy. Nonetheless, available information indicates that pacing may have a strong beneficial effect and prevents recurrence of syncope in patients with CSS. The present paper critically reviews the latest insights in the pathophysiology, diagnosis and management of CSS.

2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society

“…It occurs more commonly in men >40 years of age 413,414 and is due to an abnormal reflex attributed to baroreceptor and possibly medulla dysfunction. 415,416 Carotid sinus massage should be performed sequentially over the right and left carotid artery sinus in both the supine and upright positions for 5 seconds each, with continuous beat-to-beat heart rate monitoring and blood pressure measurement. 417 Contraindications Syncope recurred in fewer patients treated with pacing than in untreated patients, with observation periods up to 5 years.…”

Prevalência e preditores da resposta cardioinibitória à massagem do seio carotídeo em 502 pacientes ambulatoriais

“…12 Today, only asystole periods lasting ≥3 seconds are considered pathological. 1,2,11 This value is based on the experience acquired with the performance of the maneuver in thousands of individuals. Approximately 50 years ago, Franke performed CSM in 3,900 patients.…”

“…Both may occur independently (pure cardioinhibitory or vasodepressor responses), or as a combination of the two (mixed response). 1,2 Doubts still exist about the clinical meaning of the cardioinhibitory response. 3,4 CSM may produce asystole lasting ≥3 seconds in a significant portion of the population.…”

Carotid Sinus Syncope in an Elderly Patient With Unexplained Syncope

“…[17][18][19] Therefore, a decision for inserting a pacemaker should be carefully made, and even if a patient has the cardioinhibitory type of CSS. In the present case, the patient was prescribed theophylline without the insertion of a pacemaker.…”