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Carotid Sinus Hypersensitivity and Syncope in Elders

A finding of asymptomatic CSH on carotid sinus massage is only an initial step in evaluation.

The most common cause of syncope and falls in elders is carotid sinus hypersensitivity (CSH). To determine CSH prevalence in an unselected population of elders, researchers invited 1000 general practice patients age 65 or older to undergo carotid sinus massage (CSM).

Ultimately, 272 patients (median age, 71; 57% men) underwent CSM. The protocol was 5 seconds of massage over the point of maximal carotid pulsation on the left and right sides, both while the patient was supine and while tilted to 70 degrees. Cardioinhibitory CSH was defined as asystole of 3 seconds with an SBP drop of <50 mm Hg; vasodepressor CSH as an SBP drop of 50 mm Hg; and mixed CSH as a combination of the two.

One hundred seven patients (39%) exhibited CSH (6 cardioinhibitory, 42 vasodepressor, and 59 mixed); 43 of the 107 (40%) had associated symptoms, and 24 had asystole 3 seconds. Older age and male sex were the only significant predictors of CSH in a multivariable analysis. Of a subgroup of 80 patients without histories of syncope or falls, 28 (35%) had CSH, 10 of whom had associated symptoms. CSM response values above the 95th percentile were asystole lasting >7.3 seconds and an SBP drop >77 mm Hg.

Comment: This study is a sobering reminder of how many asymptomatic elderly people have abnormal responses to carotid sinus massage. Clinicians should not rush to implant pacemakers simply based on a positive response to CSM. An editorialist reminds us of the importance of determining whether symptoms accompany abnormal hemodynamic and electrocardiographic abnormalities during CSM and of being alert to other potential causes of syncope and falls. The potential clinical value of the authors’ proposal to redefine cutoff levels for carotid sinus hypersensitivity (based on their data) must be addressed in further studies.

— Hugh Calkins, MD

Published in Journal Watch Cardiology April 13, 2006

Citation(s):

Kerr SRJ et al. Carotid sinus hypersensitivity in asymptomatic older persons: Implications for diagnosis of syncope and falls. Arch Intern Med 2006 Mar 13; 166:515-20.

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Coplan NL. Carotid sinus hypersensitivity and syncope: Cause/effect or true/true/unrelated. Arch Intern Med 2006 Mar 13; 166:491-2.

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• Medline abstract (Free)