Performing Carotid Sinus Massage ROBERTO MAGGI,MICHELE BRIGNOLE Introduction Carotid sinus syndrome is a frequent cause of syncope, especially in the elderly. The initial evaluation for this condition consists of a patient history, physical examination, standard electrocardiogram (ECG) and systemic blood pressure measurement in the supine and upright positions. If the ori- gin of syncope remains uncertain, carotid sinus massage (CSM) together with the tilt test becomes the method of choice to unmask neuromediated syncopes. Performing Carotid Sinus Massage Continuous ECG monitoring must be carried out during the test. Continuous beat-to-beat noninvasive blood pressure monitoring is also important, as the vasodepressor response is rapid and cannot be adequately detected with devices that do not measure continuous blood pressure. After baseline mea- surements, the right carotid artery is firmly massaged for 5–10 s at the ante- rior margin of the sternocleidomastoid muscle at the level of the cricoid car- tilage. After 1–2 min, if the massage on one side fails to yield a “positive” response, a second massage is performed on the opposite side. If an asystolic response is evoked, then the contribution of the vasodepressor component (which may otherwise be hidden) is assessed by repeating the massage after intravenous administration of atropine (1 mg or 0.02 mg/kg body weight). The response to CSM is generally classified as cardioinhibitory (i.e., asys- Arrhythmologic Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna (GE), Italy
Performing Carotid Sinus Massage
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Introduction
Carotid sinus syndrome is a frequent cause of syncope, especially in the elderly. The initial evaluation for this condition consists of a patient history, physical examination, standard electrocardiogram (ECG) and systemic blood pressure measurement in the supine and upright positions. If the ori- gin of syncope remains uncertain, carotid sinus massage (CSM) together with the tilt test becomes the method of choice to unmask neuromediated syncopes.
Performing Carotid Sinus Massage
Continuous ECG monitoring must be carried out during the test. Continuous beat-to-beat noninvasive blood pressure monitoring is also important, as the vasodepressor response is rapid and cannot be adequately detected with devices that do not measure continuous blood pressure. After baseline mea- surements, the right carotid artery is firmly massaged for 5–10 s at the ante- rior margin of the sternocleidomastoid muscle at the level of the cricoid car- tilage. After 1–2 min, if the massage on one side fails to yield a “positive” response, a second massage is performed on the opposite side. If an asystolic response is evoked, then the contribution of the vasodepressor component (which may otherwise be hidden) is assessed by repeating the massage after intravenous administration of atropine (1 mg or 0.02 mg/kg body weight). The response to CSM is generally classified as cardioinhibitory (i.e., asys-
Arrhythmologic Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna (GE), Italy
tole), vasodepressive (fall in systolic blood pressure), or mixed. The mixed response is diagnosed by the association of an asystole of ≥ 3 s and a decline in systolic blood pressure of ≥ 50 mmHg on rhythm resumption from the baseline value (Table 1).
In general, CSM is performed by one of two different methods: • In the first, the massage is performed for a short time (usually 5 s) during
which the patient is in the supine position, and the result is defined as positive if an asystole ≥ 3 s and/or a fall in systolic blood pressure ≥ 50 mmHg are induced [1–5]. Pooled data from four studies performed in elderly patients with syncope showed a positive response rate of 35% (235 of 663 patients) [1–4]. However, previous studies found that the diagnosis may be missed in about one-third of patients if only supine massage is performed [5, 6].
• In the second method, the “method of symptoms,” CSM is performed for 10 s with the patient in the supine position and then again for another 10 s with the patient in the upright position. The test is defined as positive if during the massage the spontaneous symptoms are reproduced in associ- ation with cardioinhibition and/or vasodepression [7–11]. In an intrapa- tient comparison study [9], a higher positivity rate (49 vs 41%) in patients with syncope and a lower positivity rate (5 vs 15%) in patients without syncope were obtained with the “method of symptoms” than with the first method. In a large population of 1,719 consecutive patients
146 Roberto Maggi, Michele Brignole
Table 1. Carotid sinus massage: classification of the positive responses
• Carotid sinus massage, baseline: asystole ≥ 3 s with reproduction of spontaneous symptoms
• Carotid sinus massage after atropine: no further symptomsa
Mixed form
• Carotid sinus massage, baseline: asystole ≥ 3 s and fall in systolic blood pressure ≥ 50 mmHg with reproduction of spontaneous symptoms.
• Carotid sinus massage after atropine: milder symptoms due to systolic blood pres- sure fall ≥ 50 mmHg
Dominant vasodepressor form
• Carotid sinus massage, baseline: reproduction of the spontaneous symptoms due to systolic blood pressure fall ≥ 50 mmHg without asystole
• Carotid sinus massage after atropine: unchanged
aIn this case, the vasodepressor reflex is absent or, if present, the patient is asymptomatic
with syncope unexplained after the initial evaluation (mean age 66 ± 17 years), carotid sinus hypersensitivity was found in 56% and syncope was reproduced in 26% [12]. The positivity rate increased with age, ranging from 4% in patients < 40 years to 41% in patients > 80 years. The test was positive only in the upright position in 49% of patients. Whatever method is used, the importance of administering the massage
with the patient in the upright position, usually using a tilt table, has been recognized [5, 6, 12, 13]. In addition to yielding a higher positivity rate com- pared with supine massage only, upright massage allows for better evalua- tion of the magnitude of the vasodepressor component and for better repro- duction of symptoms. The vasodepressor component of the reflex was underestimated in the past, but is actually present in most patients who exhibit an asystolic response [13]. Correct determination of the vasodepres- sor component of the reflex is of practical importance for the choice of ther- apy. Indeed, pacemaker therapy has been shown to be less effective in mixed forms with an important vasodepressor component rather than in dominant cardioinhibitory forms [1, 14]. The syndrome is misdiagnosed in half of the patients if CSM is not performed in the upright position.
The main complications of CSM are neurological [15]. In three studies, neurological complications were reported in seven of 1,600 patients (5,000 massages), with an incidence of 0.45% [12]; in 11 of 4,000 patients (16,000 massages), with an incidence of 0.28% [16]; and in three of 1,719 patients, with an incidence of 0.17% [12]. Even if neurological complications are rare, carotid massage should be avoided in patients with previous transient ischemic attacks or strokes within the past 3 months (except if carotid Doppler studies have excluded significant stenosis) or in patients with carotid bruits [15]. Rarely, CSM may elicit self-limited atrial fibrillation of little clinical significance [17, 1]. Since asystole induced by the massage is self-terminating shortly after the end of the massage, resuscitative measures are not usually needed.
Recommendations According to the Guidelines on Syncope of the European Society of Cardiology
Indications and Methodology
Carotid sinus massage is recommended in patients > 40 years of age with syncope of unknown etiology after the initial evaluation. If there is a risk of stroke due to carotid artery disease, massage should be avoided. Electrocar- diographic monitoring and continuous blood pressure measurement during
147Performing Carotid Sinus Massage
carotid massage are mandatory. Duration of massage for a minimum of 5 and a maximum of 10 s is recommended. Carotid massage should be per- formed with the patient both supine and erect.
Diagnosis
The procedure is considered positive if syncope is reproduced during or immediately after massage in the presence of asystole > 3 s and/or a fall in systolic blood pressure ≥ 50 mmHg. A positive response is diagnostic of the cause of syncope in the absence of any other competing diagnosis.
Diagnostic Value of Carotid Sinus Massage
There is considerable disagreement regarding the diagnosis of carotid sinus syndrome (CSS); its reported prevalence ranges from 1 to 60% [1–4, 8–10, 19–21]. This discrepancy, which creates confusion and may lead to underesti- mation of the real importance of CSS, is probably due to different interpreta- tions of the results of CSM and the different indications for the test in the clinical setting. This controversy may partly be resolved by considering “spontaneous” and “induced” CSS separately. Thus, “spontaneous CSS” can be defined as syncope that, by its history, seems to occur in close relationship with accidental mechanical manipulation of the carotid sinuses and which can often be reproduced by CSM. Spontaneous CSS is rare and accounts for only about 1% of all causes of syncope [19–21]. By contrast, “induced CSS” is more broadly defined and can be assumed to be present even though a close relationship between manipulation of the carotid sinus and the occurrence of syncope is not demonstrated. Thus, induced CSS is diagnosed in patients who are found to have an abnormal response to CSM. Regarded in this way, CSS is much more frequent, with 26–60% of patients affected by unexplained syncope [1–4, 9–11]. Moreover, CSS may be responsible for many cases of syncope or unexplained “falls” in older persons. Objections could be raised that the latter definition lacks specificity and that several false-positive cases could be misinterpreted as CSS, when the real cause of syncope is different. However, this does not seem to be true; indeed, some observational and con- trolled studies have shown that pacing therapy is able to reduce syncopal relapses in patients with induced CSS [8, 20, 22–24]. In other words, the results of therapy indirectly validate the utility and efficacy of extending the indications for performing CSM according to the “method of symptoms.”
Unlike vaso-vagal syncope, which is present in young people, the preva- lence of positive CSM progressively increases with age, suggesting a phys-
148 Roberto Maggi, Michele Brignole
iopathological role of age-related degenerative processes in the genesis of the abnormal reflex. Since CSS is rare in persons under the age of 40, CSM could be limited to people older than 40 years.
The association with orthostatic blood pressure drop is more common than might otherwise be considered and suggests that an impairment of the mechanism of adaptation to the upright position is frequently involved. CSM is able to unmask this type of abnormality, which would not otherwise be revealed by the standard orthostatic hypotension testing performed during initial evaluation of syncope [6].
In conclusions, the systematic administration of “method of symptoms” CSM testing reveals that CSS is a frequent cause of syncope, especially in the elderly. Its rate is probably underestimated when the massage is not system- atically performed in patients with syncope of uncertain origin after initial evaluation.
CSS is misdiagnosed in half of the cases if the massage is not performed with the patient in the upright position. The “method of symptoms” approach is safe, with a complication rate similar to that of CSM performed according to the “short time” method.
Correlation between Carotid Sinus Massage and Spontaneous Syncope
Recently, our group prospectively evaluated whether a cardioinhibitory carotid sinus hypersensitivity (CSH) was correlated (and therefore could predict) the clinical outcome and the mechanism of implantable loop recorder (ILR)-documented spontaneous syncope [25]. The correlation of spontaneous syncopal episodes with an abnormal ILR finding can be regard- ed as a reference standard when an arrhythmia is suspected to have a role in the genesis of syncope.
The study included 18 consecutive patients with suspected recurrent neu- rally mediated syncope and a positive cardioinhibitory response during CSM (maximum pause 5.5 ± 1.6 s) who had subsequent documentation of a spon- taneous syncope by means of an ILR. The patients were compared with a 2:1 age- and sex-matched group of 36 patients with a clinical diagnosis of recur- rent neurally mediated syncope and negative response to CSM, tilt testing, and ATP test. Asystole > 3 s was observed at the time of the spontaneous syn- cope in 16 (89%) of the CSH patients and in 18 (50%) of the control group (p = 0.007). Sinus arrest was the most frequent finding among CSH patients but not among controls (72 vs 28%, p = 0.003). After ILR documentation, 14 CSH patients with asystole received dual-chamber pacemaker implantation; dur- ing 35 ± 22 months of follow-up, two syncopal episodes recurred in two
149Performing Carotid Sinus Massage
patients (14%) and presyncope occurred in another two patients (14%). Syncope burden decreased from 1.68 (95%, confidence interval 1.66–1.70) episodes per patient per year before to 0.04 (0.038–0.042) after pacemaker implant (98% relative risk reduction).
In this study we found that a long asystole, mainly due to sinus arrest, was the most frequent finding at the time of spontaneous syncope in patients with cardioinhibitory CSH. In patients with a clinical diagnosis of suspected neurally mediated syncope, the finding of a cardionihibitory response during carotid sinus massage predicted, with a probability of 89%, that a long asys- tolic reflex was also present at the time of the spontaneous syncope. The finding of progressive sinus bradycardia followed by ventricular asystole (types 1A and 1B of the ISSUE classification [26] was consistent with the eti- ology of neurally mediated syncope. In the absence of a cardioinhibitory CSH, the electrocardiographic findings at the time of spontaneous neurally mediated syncope were heterogeneous, with bradycardia or asystole account- ing for only approximately one-half of the syncope events [26].
The finding of asystolic syncope during spontaneous episodes forms the background for the potential benefit of cardiac pacing in CSH patients. Indeed, according to our study, cardiac pacing resulted in a 98% reduction of the syncope burden during 3 years of follow-up.
References
1. Mc Intosh SJ, Lawson J, Kenny RA (1993) Clinical characteristics of vasodepressor, cardioinhibitory and mixed carotid sinus syndrome in the elderly. Am J Med 95:203–208
2. Graux P, Mekerke W, Lemaire N et al (1989) Le syndrome du sinus carotidien. Apport de la monitorisation de la pression arterielle a l’exploration electrophysio- logique endocavitaire. Arch Mal Coeur 82:193–199
3. Huang SKS, Ezri MD, Honser RG, Denes P (1988) Carotid sinus hypersensitivity in patients with unexplained syncope: clinical, electrophysiologic, and long-term fol- low-up observation. Am Heart J 116:989–996
4. Volkmann H, Schnerch B, Kuhnert H (1990) Diagnostic value of carotid sinus hypersensitivity. Pacing Clin Electrophysiol 13:2065–2070
5. Parry SW, Richardson D, O’Shea D et al (2000) Diagnosis of carotid sinus hyper- sensitivity in older adults: carotid sinus massage in the upright position is essen- tial. Heart 83:22–23
6. Brignole M, Sartore B, Prato R (1983) Role of body position during carotid sinus stimulation test in the diagnosis of cardioinhibitory carotid sinus syndrome. G Ital Cardiol 14:69–72
7. Thomas JE (1969) Hyperactive carotid sinus reflex and carotid sinus syncope. Mayo Clin Proc 44:127–139
8. Brignole M, Menozzi C, Lolli G et al (1992) Long-term outcome of paced and non paced patients with severe carotid sinus syndrome. Am J Cardiol 69:1039–1043
150 Roberto Maggi, Michele Brignole
9. Brignole M, Menozzi C (1992) Carotid sinus syndrome: diagnosis, natural history and treatment. Eur J Cardiac Pacing Electrophysiol 4:247–254
10. Brignole M, Menozzi C, Gianfranchi L et al (1991) Carotid sinus massage, eyeball compression and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J 122:1644–1651
11. Brignole M, Menozzi C, Gianfranchi L et al (1991) Neurally mediated syncope detected by carotid sinus massage and head-up tilt test in sick sinus syndrome. Am J Cardiol 68:1032–1036
12. Puggioni E, Guiducci V, Brignole M et al (2002) Results and complications of the carotid sinus massage performed according to the “Methods of Symptoms”. Am J Cardiol 89:599–601
13. Gaggioli G, Brignole M, Menozzi C et al (1995) Reappraisal of the vasodepressor reflex in carotid sinus syndrome. Am J Cardiol 75:518–521
14. Brignole M, Menozzi C, Lolli G et al (1991) Validation of a method for choice of pacing mode in carotid sinus syndrome with or without sinus bradycardia. Pacing Clin Electrophysiol 14:196–203
15. Munro N, McIntosh S, Lawson J et al (1994) The incidence of complications after carotid sinus massage in older patients with syncope. J Am Geriatr Soc 42:1248–1251
16. Davies AG, Kenny RA (1998) Neurological complications following carotid sinus massage. Am J Cardiol 81:1256–1257
17. Franke H (1963) Uber das karotissinus-syndrome und den sogennanten hyperacti- ven karotissinus reflex. Fridrich-Kave Schattaueur, Stuttgart
18. Brignole M, Alboni P, Benditt DG et al (2004) Guidelines on management (diagno- sis and treatment) of syncope – Update 2004. Europace 6:467–537
19. Kapoor W, Snustad D, Peterson J et al (1986) Syncope in the elderly. Am J Med 80:419–427
20. Mathias CJ, Deguchi K, Schatz I (2001) Observation on recurrent syncope and pre- syncope in 641 patients. Lancet 357:348–353
21. Ammirati F, Colivicchi F, Santini M (2000) Diagnosing syncope in clinical practice. Eur Heart J 21:935–940
22. Morley CA, Perrins EJ, Chan SL, Sutton R (1983) Long-term comparison of DVI and VVI pacing in carotid sinus syndrome. In: Steinbach K (ed) Proceedings of the VII World Symposium on Cardiac Pacing. Steinkopff Verlag, Darmstadt, pp 929–935
23. Stryjer D, Friedensohn A, Schlesinger Z (1986) Ventricular pacing as the preferable mode for lomg-term pacing in patients with carotid sinus syncope of the car- dioinhibitory type. Pacing Clin Electrophysiol 9:705–709
24. Blanc JJ, Boshat J, Penther Ph (1984) Hypersensibilité sino-carotidienne. Evolution à moyen terme en fonction du traitement et de ses symptomes. Arch Mal Coeur 77:330–336
25. Maggi R, Menozzi C, Brignole M et al (2007) Cardioinhibitory carotid sinus hyper- sensitivity predicts an asystolic mechanism of spontaneous neurally-mediated syncope. Europace (in press)
26. Brignole M, Moya A, Menozzi C et al (2005) Proposed electrocardiographic classifi- cation of spontaneous syncope documented by an implantable loop recorder. Europace 7:14–18
151Performing Carotid Sinus Massage
Carotid sinus syndrome is a frequent cause of syncope, especially in the elderly. The initial evaluation for this condition consists of a patient history, physical examination, standard electrocardiogram (ECG) and systemic blood pressure measurement in the supine and upright positions. If the ori- gin of syncope remains uncertain, carotid sinus massage (CSM) together with the tilt test becomes the method of choice to unmask neuromediated syncopes.
Performing Carotid Sinus Massage
Continuous ECG monitoring must be carried out during the test. Continuous beat-to-beat noninvasive blood pressure monitoring is also important, as the vasodepressor response is rapid and cannot be adequately detected with devices that do not measure continuous blood pressure. After baseline mea- surements, the right carotid artery is firmly massaged for 5–10 s at the ante- rior margin of the sternocleidomastoid muscle at the level of the cricoid car- tilage. After 1–2 min, if the massage on one side fails to yield a “positive” response, a second massage is performed on the opposite side. If an asystolic response is evoked, then the contribution of the vasodepressor component (which may otherwise be hidden) is assessed by repeating the massage after intravenous administration of atropine (1 mg or 0.02 mg/kg body weight). The response to CSM is generally classified as cardioinhibitory (i.e., asys-
Arrhythmologic Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna (GE), Italy
tole), vasodepressive (fall in systolic blood pressure), or mixed. The mixed response is diagnosed by the association of an asystole of ≥ 3 s and a decline in systolic blood pressure of ≥ 50 mmHg on rhythm resumption from the baseline value (Table 1).
In general, CSM is performed by one of two different methods: • In the first, the massage is performed for a short time (usually 5 s) during
which the patient is in the supine position, and the result is defined as positive if an asystole ≥ 3 s and/or a fall in systolic blood pressure ≥ 50 mmHg are induced [1–5]. Pooled data from four studies performed in elderly patients with syncope showed a positive response rate of 35% (235 of 663 patients) [1–4]. However, previous studies found that the diagnosis may be missed in about one-third of patients if only supine massage is performed [5, 6].
• In the second method, the “method of symptoms,” CSM is performed for 10 s with the patient in the supine position and then again for another 10 s with the patient in the upright position. The test is defined as positive if during the massage the spontaneous symptoms are reproduced in associ- ation with cardioinhibition and/or vasodepression [7–11]. In an intrapa- tient comparison study [9], a higher positivity rate (49 vs 41%) in patients with syncope and a lower positivity rate (5 vs 15%) in patients without syncope were obtained with the “method of symptoms” than with the first method. In a large population of 1,719 consecutive patients
146 Roberto Maggi, Michele Brignole
Table 1. Carotid sinus massage: classification of the positive responses
• Carotid sinus massage, baseline: asystole ≥ 3 s with reproduction of spontaneous symptoms
• Carotid sinus massage after atropine: no further symptomsa
Mixed form
• Carotid sinus massage, baseline: asystole ≥ 3 s and fall in systolic blood pressure ≥ 50 mmHg with reproduction of spontaneous symptoms.
• Carotid sinus massage after atropine: milder symptoms due to systolic blood pres- sure fall ≥ 50 mmHg
Dominant vasodepressor form
• Carotid sinus massage, baseline: reproduction of the spontaneous symptoms due to systolic blood pressure fall ≥ 50 mmHg without asystole
• Carotid sinus massage after atropine: unchanged
aIn this case, the vasodepressor reflex is absent or, if present, the patient is asymptomatic
with syncope unexplained after the initial evaluation (mean age 66 ± 17 years), carotid sinus hypersensitivity was found in 56% and syncope was reproduced in 26% [12]. The positivity rate increased with age, ranging from 4% in patients < 40 years to 41% in patients > 80 years. The test was positive only in the upright position in 49% of patients. Whatever method is used, the importance of administering the massage
with the patient in the upright position, usually using a tilt table, has been recognized [5, 6, 12, 13]. In addition to yielding a higher positivity rate com- pared with supine massage only, upright massage allows for better evalua- tion of the magnitude of the vasodepressor component and for better repro- duction of symptoms. The vasodepressor component of the reflex was underestimated in the past, but is actually present in most patients who exhibit an asystolic response [13]. Correct determination of the vasodepres- sor component of the reflex is of practical importance for the choice of ther- apy. Indeed, pacemaker therapy has been shown to be less effective in mixed forms with an important vasodepressor component rather than in dominant cardioinhibitory forms [1, 14]. The syndrome is misdiagnosed in half of the patients if CSM is not performed in the upright position.
The main complications of CSM are neurological [15]. In three studies, neurological complications were reported in seven of 1,600 patients (5,000 massages), with an incidence of 0.45% [12]; in 11 of 4,000 patients (16,000 massages), with an incidence of 0.28% [16]; and in three of 1,719 patients, with an incidence of 0.17% [12]. Even if neurological complications are rare, carotid massage should be avoided in patients with previous transient ischemic attacks or strokes within the past 3 months (except if carotid Doppler studies have excluded significant stenosis) or in patients with carotid bruits [15]. Rarely, CSM may elicit self-limited atrial fibrillation of little clinical significance [17, 1]. Since asystole induced by the massage is self-terminating shortly after the end of the massage, resuscitative measures are not usually needed.
Recommendations According to the Guidelines on Syncope of the European Society of Cardiology
Indications and Methodology
Carotid sinus massage is recommended in patients > 40 years of age with syncope of unknown etiology after the initial evaluation. If there is a risk of stroke due to carotid artery disease, massage should be avoided. Electrocar- diographic monitoring and continuous blood pressure measurement during
147Performing Carotid Sinus Massage
carotid massage are mandatory. Duration of massage for a minimum of 5 and a maximum of 10 s is recommended. Carotid massage should be per- formed with the patient both supine and erect.
Diagnosis
The procedure is considered positive if syncope is reproduced during or immediately after massage in the presence of asystole > 3 s and/or a fall in systolic blood pressure ≥ 50 mmHg. A positive response is diagnostic of the cause of syncope in the absence of any other competing diagnosis.
Diagnostic Value of Carotid Sinus Massage
There is considerable disagreement regarding the diagnosis of carotid sinus syndrome (CSS); its reported prevalence ranges from 1 to 60% [1–4, 8–10, 19–21]. This discrepancy, which creates confusion and may lead to underesti- mation of the real importance of CSS, is probably due to different interpreta- tions of the results of CSM and the different indications for the test in the clinical setting. This controversy may partly be resolved by considering “spontaneous” and “induced” CSS separately. Thus, “spontaneous CSS” can be defined as syncope that, by its history, seems to occur in close relationship with accidental mechanical manipulation of the carotid sinuses and which can often be reproduced by CSM. Spontaneous CSS is rare and accounts for only about 1% of all causes of syncope [19–21]. By contrast, “induced CSS” is more broadly defined and can be assumed to be present even though a close relationship between manipulation of the carotid sinus and the occurrence of syncope is not demonstrated. Thus, induced CSS is diagnosed in patients who are found to have an abnormal response to CSM. Regarded in this way, CSS is much more frequent, with 26–60% of patients affected by unexplained syncope [1–4, 9–11]. Moreover, CSS may be responsible for many cases of syncope or unexplained “falls” in older persons. Objections could be raised that the latter definition lacks specificity and that several false-positive cases could be misinterpreted as CSS, when the real cause of syncope is different. However, this does not seem to be true; indeed, some observational and con- trolled studies have shown that pacing therapy is able to reduce syncopal relapses in patients with induced CSS [8, 20, 22–24]. In other words, the results of therapy indirectly validate the utility and efficacy of extending the indications for performing CSM according to the “method of symptoms.”
Unlike vaso-vagal syncope, which is present in young people, the preva- lence of positive CSM progressively increases with age, suggesting a phys-
148 Roberto Maggi, Michele Brignole
iopathological role of age-related degenerative processes in the genesis of the abnormal reflex. Since CSS is rare in persons under the age of 40, CSM could be limited to people older than 40 years.
The association with orthostatic blood pressure drop is more common than might otherwise be considered and suggests that an impairment of the mechanism of adaptation to the upright position is frequently involved. CSM is able to unmask this type of abnormality, which would not otherwise be revealed by the standard orthostatic hypotension testing performed during initial evaluation of syncope [6].
In conclusions, the systematic administration of “method of symptoms” CSM testing reveals that CSS is a frequent cause of syncope, especially in the elderly. Its rate is probably underestimated when the massage is not system- atically performed in patients with syncope of uncertain origin after initial evaluation.
CSS is misdiagnosed in half of the cases if the massage is not performed with the patient in the upright position. The “method of symptoms” approach is safe, with a complication rate similar to that of CSM performed according to the “short time” method.
Correlation between Carotid Sinus Massage and Spontaneous Syncope
Recently, our group prospectively evaluated whether a cardioinhibitory carotid sinus hypersensitivity (CSH) was correlated (and therefore could predict) the clinical outcome and the mechanism of implantable loop recorder (ILR)-documented spontaneous syncope [25]. The correlation of spontaneous syncopal episodes with an abnormal ILR finding can be regard- ed as a reference standard when an arrhythmia is suspected to have a role in the genesis of syncope.
The study included 18 consecutive patients with suspected recurrent neu- rally mediated syncope and a positive cardioinhibitory response during CSM (maximum pause 5.5 ± 1.6 s) who had subsequent documentation of a spon- taneous syncope by means of an ILR. The patients were compared with a 2:1 age- and sex-matched group of 36 patients with a clinical diagnosis of recur- rent neurally mediated syncope and negative response to CSM, tilt testing, and ATP test. Asystole > 3 s was observed at the time of the spontaneous syn- cope in 16 (89%) of the CSH patients and in 18 (50%) of the control group (p = 0.007). Sinus arrest was the most frequent finding among CSH patients but not among controls (72 vs 28%, p = 0.003). After ILR documentation, 14 CSH patients with asystole received dual-chamber pacemaker implantation; dur- ing 35 ± 22 months of follow-up, two syncopal episodes recurred in two
149Performing Carotid Sinus Massage
patients (14%) and presyncope occurred in another two patients (14%). Syncope burden decreased from 1.68 (95%, confidence interval 1.66–1.70) episodes per patient per year before to 0.04 (0.038–0.042) after pacemaker implant (98% relative risk reduction).
In this study we found that a long asystole, mainly due to sinus arrest, was the most frequent finding at the time of spontaneous syncope in patients with cardioinhibitory CSH. In patients with a clinical diagnosis of suspected neurally mediated syncope, the finding of a cardionihibitory response during carotid sinus massage predicted, with a probability of 89%, that a long asys- tolic reflex was also present at the time of the spontaneous syncope. The finding of progressive sinus bradycardia followed by ventricular asystole (types 1A and 1B of the ISSUE classification [26] was consistent with the eti- ology of neurally mediated syncope. In the absence of a cardioinhibitory CSH, the electrocardiographic findings at the time of spontaneous neurally mediated syncope were heterogeneous, with bradycardia or asystole account- ing for only approximately one-half of the syncope events [26].
The finding of asystolic syncope during spontaneous episodes forms the background for the potential benefit of cardiac pacing in CSH patients. Indeed, according to our study, cardiac pacing resulted in a 98% reduction of the syncope burden during 3 years of follow-up.
References
1. Mc Intosh SJ, Lawson J, Kenny RA (1993) Clinical characteristics of vasodepressor, cardioinhibitory and mixed carotid sinus syndrome in the elderly. Am J Med 95:203–208
2. Graux P, Mekerke W, Lemaire N et al (1989) Le syndrome du sinus carotidien. Apport de la monitorisation de la pression arterielle a l’exploration electrophysio- logique endocavitaire. Arch Mal Coeur 82:193–199
3. Huang SKS, Ezri MD, Honser RG, Denes P (1988) Carotid sinus hypersensitivity in patients with unexplained syncope: clinical, electrophysiologic, and long-term fol- low-up observation. Am Heart J 116:989–996
4. Volkmann H, Schnerch B, Kuhnert H (1990) Diagnostic value of carotid sinus hypersensitivity. Pacing Clin Electrophysiol 13:2065–2070
5. Parry SW, Richardson D, O’Shea D et al (2000) Diagnosis of carotid sinus hyper- sensitivity in older adults: carotid sinus massage in the upright position is essen- tial. Heart 83:22–23
6. Brignole M, Sartore B, Prato R (1983) Role of body position during carotid sinus stimulation test in the diagnosis of cardioinhibitory carotid sinus syndrome. G Ital Cardiol 14:69–72
7. Thomas JE (1969) Hyperactive carotid sinus reflex and carotid sinus syncope. Mayo Clin Proc 44:127–139
8. Brignole M, Menozzi C, Lolli G et al (1992) Long-term outcome of paced and non paced patients with severe carotid sinus syndrome. Am J Cardiol 69:1039–1043
150 Roberto Maggi, Michele Brignole
9. Brignole M, Menozzi C (1992) Carotid sinus syndrome: diagnosis, natural history and treatment. Eur J Cardiac Pacing Electrophysiol 4:247–254
10. Brignole M, Menozzi C, Gianfranchi L et al (1991) Carotid sinus massage, eyeball compression and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J 122:1644–1651
11. Brignole M, Menozzi C, Gianfranchi L et al (1991) Neurally mediated syncope detected by carotid sinus massage and head-up tilt test in sick sinus syndrome. Am J Cardiol 68:1032–1036
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