Roberto Maggi Centro Aritmologicoe Syncope Unit–Lavagna ... · PDF fileRoberto Maggi Centro Aritmologicoe Syncope Unit–Lavagna, Italia TigullioCardiologia, 7 aprile 2016. Carotid

Ilmassaggio delseno carotideoRobertoMaggi

CentroAritmologico eSyncope Unit – Lavagna,Italia

Tigullio Cardiologia,7aprile2016

Carotid sinus hypersensitivity Glossopharyngeal

nerveGlossopharyngeal nerve

Vagus nerveVagus nerve

Carotid sinus nerveCarotid sinus nerve

Carotid sinus Carotid sinus

CS reflex arc

Carotid sinus massage responses:

Ageing process?

Syndrome?

CSM is the tool for evaluation of CS reflex arc function

Age (years)

% CSS

Patients 205 161 240 415 462 236

Results and complications of CSM. Puggioni E et al. Am J Cardiol 2002

10 20 30 40 50 60 70 80Age at onset

ClassicalVVS

Situational Non-classicalVVS

Carotid sinus

Age of onset of Reflex SyncopeAge of onset of Reflex Syncope

Carotid sinus syndrome“Method of Symptoms”

• Carotid sinus hypersensitivity (CSH):asystole ≥3 sec and/or SBP fall ≥ 50 mmHg(irrespective of symptoms)

• Carotid sinus syndrome (CSS):reproduction of syncope in presence of CSH

• Carotid sinus hypersensitivity (CSH):asystole ≥3 sec and/or SBP fall ≥ 50 mmHg(irrespective of symptoms)

• Carotid sinus syndrome (CSS):reproduction of syncope in presence of CSH

Definitions

Brignole M et al. Eur Heart J 2004 25, 2054–2072Moya A. et al. Eur Heart J. 2009;30:2631–2671

Low specificity of CSH !!!

272 participants sampled from a single general practice register who underwent supine and upright CSM

Pacing in elderly recurrent fallers with carotid sinushypersensitivity: a RCT crossover trial

Parry S, et al. Heart 2009

Asyndrome isasetofmedicalsigns andsymptoms thatarecorrelatedwitheachotherandoftenwithaspecificdisease

CSS: definition

Clinical features compatible with CSS +Reproduction of syncope

by means of CSM

SyncopeUnitProject2(SUP2)

• Certain or suspected reflex syncopes

• Short (<10”) or no prodromes

• Recurrent

• Severe, i.e., unpredictable

• Onset in older age

EurHeartJ 2015;36:1529–35

Number of patients n=66

Age 77±9

Men 68%

Syncope events:

- Total syncopes, median 4 (3-6)

- Syncopes in the previous 2 years, median 3 (2-4)

- Age on first syncope 70±16

- Syncopes without or with prodromes <10 s, 88%

- Hospitalization for syncope 55%

- Injuries related to fainting

- Major injuries 11%

- Minor injuries 69%

Medical history

- Structural cardiac abnormalities 23%

- ECG abnormalities 25%

- Hypertension 58%

- Diabetes 19%

- Neurological/psychiatric disorders 16%

Concomitant vasoactive medications 59%

Typical features of CSS

Clinical features of CSS

SyncopeUnitProject2(SUP2) CSS(n=66patients)

EuropeanHeartJournal 2015;36:1529–35

95%

5% Vasovagal prodromes

Noprodromes

Carotid sinus massage: “Method of Symptoms”

Positive responseCSS is established if spontaneous symptoms (syncope or presyncope) are reproduced in presence of hypotension ± asystolic pause

Positive responseCSS is established if spontaneous symptoms (syncope or presyncope) are reproduced in presence of hypotension ± asystolic pause

No cut-off value of SBP fall or asystolic pause is required

Solari D et al. Circ Arrhythm Electrophysiol 2014; 7: 505-510

Brignole et al. Am J Cardiol 1992; 69: 1039-1043

Cardiac pacing in CSS by Method of Symptoms

Study PM groupn/N

No PM groupn/N

Sugrue1986

2/23 7/33

Brignole1992 (a)

3/32 16/28

Claesson2007

3/30 12/30

Total 8/85 35/91

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

Relative risk 95% CI

PM better No PM better

Relative risk 95% CI

0.41 (0.10-1.56)

0.16 (0.06-0.40)

0.33 (0.10-0.97)

0.24 (0.12-0.48)

Testforheterogeneity:p=0.39

Cardiac pacing in CSS by Method of Symptoms

Europace 2011; 13: 462–464

CSH+ ILR+

18Asystole Asystole89%

11% Noasystole

16

2

Total18pts

ISSUE 2

SYNCOPE

Cardioinhibitory carotidsinushypersensitivitypredictsanasystolicmechanismofspontaneous neurally-mediatedsyncope

Maggiet al.Europace2007;9,563–567

Conclusions

1.CSH is an ageing process

2.CSS is an ageing-related syndrome

3.The underlying disease is poorly understood

Carotid sinus massageresponses


Carotid Sinus Massage (CSM)Carotid Sinus Massage (CSM)

• CSM is raccomanded in patients over age 40years with uncertain syncope

• A positive response is diagnostic if no competing diagnosis

• In case of risk of stroke, avoid massage

• CSM is raccomanded in patients over age 40years with uncertain syncope

• A positive response is diagnostic if no competing diagnosis

• In case of risk of stroke, avoid massage

Carotid sinus massage:“Method of Symptoms”

Complications of CSMComplications of CSM

Method ofsymptoms:3TIA(0.17%)Puggioni et al.AmJCardiol.2002Mar1;89(5):599-601

ShortMethod:0.28%- 0.45%complications(Munro1994&Davies 1998)

Carotid sinus massage: “Method of Symptoms”Carotid sinus massage: “Method of Symptoms”

Method

• Ecg monitoring and continuous BPmeasurement during carotid massage

• Duration of massage of 10 seconds (interrupted in case of syncope)

• Massage both supine and erect, on the right and left sinuses separately

• (in case of asystole) massage repeated after atropine 0.02 mg/Kg i.v.

Method

• Ecg monitoring and continuous BPmeasurement during carotid massage

• Duration of massage of 10 seconds (interrupted in case of syncope)

• Massage both supine and erect, on the right and left sinuses separately

• (in case of asystole) massage repeated after atropine 0.02 mg/Kg i.v.

ESC Task Force on Management (Diagnosis and Treatment) of Syncope

“Method of Symptoms”: CI form

100

0

BPON OFF10 s

Syncope

BaselineBaseline

Atropine 0.02 mg/Kg i.v.Atropine 0.02 mg/Kg i.v.

100

0

BPON OFF10 s

No symptoms

“Method of Symptoms”: MIXED form

150

0

BPON OFF10 s

S

ON OFF11 s150

0

BP

Syncope

Syncope

Atropine 0.02 mg/Kg i.v.Atropine 0.02 mg/Kg i.v.

BaselineBaseline

Carotid sinus syndromeClassification of the positive responses

Cardioinhibitory form: • CSM after atropine: no more symptoms

Mixed form:• CSM after atropine: milder symptoms due to SBP fall ≥50 mmHg

Vasodepressor form:

• Baseline CSM: fall of SBP >50 mmHg with reproduction ofspontaneous symptoms (no asystole >3 sec)

Europace (2011) 13, 572–575

Recurrence CI: 13% Recurrence Mixed: 38%

CSM, EBC & HUT in 100 patients with syncope Brignole M et al. Am Heart J 1991; 122: 1644

Positive 79 ptsNegative 21 pts

24

CSM49%

HUT43%

EBC16%

19 20

24

8

2

Positive responses

Mean age 60±18

Actuarial estimates:

• 7% at 1 year

• 16% at 3 years

• 20% at 5 years

CSS: recurrence of syncope with cardiac pacing

PuggioniEetal.AmJCardiol 2002;89:599

Am J Cardiol 1995; 76: 720

Pm, TT negative

Pm, TT Positive

No Pm, ILRLog rank for trend:p = 0.01

p = 0.03

SyncopeUnitProject2(SUP2) SUP 2 study: 3-years extended follow-up

Europace 2015

Critical issues for pacing in CSS

• Mixed forms of CSS, i.e., important VD reflex

• Associated positivity of tilt testing, i.e., hypotensive susceptibility

Cardiac pacing is effective in CSS, butsyncope is more likely to recur in presence of:

CSS: the underlying disease (I)

Age-related degenerative CNS disease ? (impairment of compensatory baroreflexes

and cardiac SN effectors?)


CSS is frequently associated with otherabnormal reflexes, but not with typical VVS

APL, μM

Adenosine phenotypes and neurally-mediated syncope

n=57 n=9 n=23 n=30 n=40

GuieuRetal.Adenosine andclinical forms.JACC2015;66:202-3

1. CSS, a form of “Low Adenosine” disease ?

2. “Low Adenosine” disease is different from

Vasovagal syncope

CSS: the underlying disease (II)


ConclusionsConclusions

• CSH is not a precursor of CSS• CSS is a frequent cause of syncope

• CSM should be performed systematicallyin the patients after the initial evaluation

• CSM must be performed in upright position (49% false negative rate if only supine)

• The “Method of Symptoms” is safe, with a low complications rate

10 20 30 40 50 60 70 80

1,2

1,0

0,8

0,6

0,4

0,2

0,0

Age

APL

20 30 40 50 60 70 80 90

2,0

1,5

1,0

0,5

0,0

Age

APL

20 30 40 50 60 70 80

0,8

0,7

0,6

0,5

0,4

0,3

Age

APL

P=0.54

Control group No prodromes and CSS groups

P=0.49

P=0.92

Situational group

10 20 30 40 50 60 70 80

3,5

3,0

2,5

2,0

1,5

1,0

0,5

0,0

Age

APL

VVS group

P=0.70

712

63

0

17

74

50

26

4250

19

38

11

58

33

0

10

20

30

40

50

60

70

80

Noprodr n=27

CSSn=8

Sitn=19

VVSn=12

Cntrn=40

TT

TC

CC

%

GenotypeoftheA2A Rgeneplomorphism

Adenosine phenotypes and neurally-mediated syncope


Summary

Ageing process? Syndrome ?

1. CSH is an ageing process

2. CSS is an age-related

syndrome

Which is the underlyingdisease ?

3. Age-related degenerative

CNS disease ?

4. A form of “Low Adenosine”

disease ?

5. “Low Adenosine” disease is

different from VasoVagal

syncope

Dowereallyunderstandcarotidsinusmassageresponses?

CSM, EBC & HUT in 100 patients with syncope Brignole M et al. Am Heart J 1991; 122: 1644

Positive CSM 49 ptsSituational 39 pts

26

Situational CSM +

13 36

No prodromes Low AplLow A2AR

TC variant

Controls

NormalAPl

SituationalHigh APLCC variant

VVS

High A2AR

NormalA2AR

TT variant

CSS


No prodromes & CSS

Low AplLow A2AR

TC variant

Controls

NormalAPl

SituationalHigh APLCC variant

VVS

High A2AR

NormalA2AR

TT variant


• CSHis very frequent inolder people

• 39%CSHinan unselected cohort

• 35%CSHinolder peoplewith nohystory of syncope orfalls

• Syncope occurred only inaminority of patients with CSH

Occ Arch Int Med.2006;166:515-20

Heart 2010; 96: 347-351

Inclusion criteria

• Unexplained falls that is: 1) no clear history of a trip; and 2) denial of loss of consciousness

• CSH (3 sec asystole)

PM ILR p

Falls 3.4 ± 6.6 1.4 ± 2.1 .07

Syncope 0.32 ± 0.82 0.35 ± 1.08 .25

…current criteria for CSH are too sensitive, and this may well be the underlying reason for the reported high prevalence of CSH in the general older population

NewcriteriasuggestedforCSH

• Spontaneousclinicalsymptomsand

• Asystole of≥6sand/or

• Afallinmeanarterialpressurebelow60mmHglastingfor≥6s

PPVCI form

(n=86 pts)Mixed form (n= 46 pts)

Max asystolic pause, s

Max asystolic pause, s

99% 3.2 4.095% 4.6 4.490% 5.0 4.975% 6.0 5.750% 7.9 7.5

25% 9.1 8.610% 10.0 10.05% 11.0 12.01% 13.2 12.0

CSS by Method of Symptoms

Solari D et al. Circ Arrhythm Electrophysiol 2014; 7: 505-510

SSS & NMSBrignole et al. Am J Cardiol 1991; 68: 1032-6

20%

20%

34%

26%CSM +

HUT +CSM/HUT +

Negative

35 pts with SSS and syncope

CSSTherapy:pacemakerimplantation

Classe Raccomandazioni per il trattamento delle sincopi

neuromediate

Evidenza

IElettrostimolazione cardiaca nei pazienti con sindrome seno carotidea a prevalente componente cardioinibitrice

B

CSSTherapy:isPMreallyeffective?

Brignole,2011

Brignole,2011

RRR of syncope recurrence after PM in controlledstudies in which CCS was diagnosed by means of the

“Method of Symptoms”

Carotidsinusmassage

WhyperformCSM?

• A positive response to CSM is frequent (from 4% inpatients >40 yrs to 41% in pts >80 yrs)

• CSS is common in older patients with unexplainedfalls

• Major trauma are more frequent in CSS than to theother pts with syncope evaluated in ED

• CSS can be treated in order to reduce syncopeburden


CSM sequence:• Supine right massage ≥10 sec• Supine left massage ≥10 sec• Orthostatic blood pressure drop • Standing right massage ≥10 sec• Standing left massage ≥10 sec• (in case of asystole) massage repeated

after atropine 0.02 mg/Kg i.v.

CSM sequence:• Supine right massage ≥10 sec• Supine left massage ≥10 sec• Orthostatic blood pressure drop • Standing right massage ≥10 sec• Standing left massage ≥10 sec• (in case of asystole) massage repeated

after atropine 0.02 mg/Kg i.v.



• Neck rotated contralaterally• Anterior margin of the sternocleomastoid

muscle at the level of the cricoid cartilage• 3 fingers over the zone of maximum

carotid artery pulse• Firm massage for 10 sec or till syncope

occurs

ConclusionsConclusions

• CSS is a frequent cause of syncope in the elderly.

• CSM should be performed systematically in the patients after the initial evaluation

• CSM must be performed in upright position (49% false negative rate if only supine)

• The “Method of Symptoms” is safe, with a low complications rate

ISSUE 2International Study on Syncope of Uncertain Etiology 2

ISSUE 2

SYNCOPE

Conclusions• A long asystole, mainly due to sinus arrest, is the mostfrequent finding at the time of spontaneous syncope inpatients with cardioinhibitory CSH and is consistent withthe aetiology of neurally-mediated syncope.

• A cardioinhibitory response during CSM predicts, with aprobability of 89%, that a long asystolic reflex is alsopresent at the time of spontaneous syncope.

• The finding of asystolic syncope during spontaneousepisodes forms the background for the potential benefitof cardiac pacing in CSH patients (98% reduction of thesyncope burden in this study)

Carotid sinus syndromeCarotid sinus syndrome


Spontaneous carotid sinus syndrome: close relationship with accidental mechanical manipulation of the carotid sinuses, reproduced by carotid sinus massage. Rare, about 1% of all causes of syncope

Induced carotid sinus syndrome: abnormal response to carotid sinus massage and an otherwise negative work-up. Much more frequent, 26% to 60% of patients affected by unexplained syncope

Spontaneous carotid sinus syndrome: close relationship with accidental mechanical manipulation of the carotid sinuses, reproduced by carotid sinus massage. Rare, about 1% of all causes of syncope

Induced carotid sinus syndrome: abnormal response to carotid sinus massage and an otherwise negative work-up. Much more frequent, 26% to 60% of patients affected by unexplained syncope

CSM:MethodofSymptoms”

Theprocedureisconsideredpositiveifsymptomsarereproduced inpresenceofasystole≥3 secand/orafallinSBP≥50mmHg

Apositiveresponse(symptomreproduction)isdiagnosticofthecauseofsyncopeintheabsenceofanyothercompetingdiagnosis

ESCTaskForceonManagement(DiagnosisandTreatment)ofSyncope,2009

WhenCSMispositive?

WhenCSMisdiagnostic?


Positive response• The procedure is considered positive if

symptoms are reproduced in presence of asystole ≥3 sec and/or a fall in SBP ≥50 mmHg.

• A positive response is diagnostic of the cause of syncope in the absence of any other competing diagnosis

Positive response• The procedure is considered positive if

symptoms are reproduced in presence of asystole ≥3 sec and/or a fall in SBP ≥50 mmHg.

• A positive response is diagnostic of the cause of syncope in the absence of any other competing diagnosis


0,00% 10,00% 20,00% 30,00% 40,00% 50,00% 60,00% 70,00%

Howfrequentiscarotidsinusmassage?

EGSYSh

ospitals

Percentpatients

50th25th 75th maxmin

12%3%0% 58%23%

Roberto Maggi Centro Aritmologicoe Syncope Unit–Lavagna ... · PDF fileRoberto Maggi Centro Aritmologicoe Syncope Unit–Lavagna, Italia TigullioCardiologia, 7 aprile 2016. Carotid

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