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Y Lei L, S Chew D, K Sandhu R, S Sheldon R, R Raj S. Non-Pharmacological and Pharmacological Management of Cardiac Dysautonomia Syndromes. J Atr Fibrillation 2020; 13:2395. [PMID: 33024496 DOI: 10.4022/jafib.2395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/10/2020] [Accepted: 03/16/2020] [Indexed: 11/10/2022]
Abstract
Vasovagal syncope, postural orthostatic tachycardia syndrome, and inappropriate sinus tachycardia comprise a heterogenous group of common autonomic disorders that are associated with significant symptoms that impair quality of life. Clinical management of these disorders should prioritize conservative non-pharmacological therapies and consider incorporating pharmacological agents for recurrences. The selection and titration of medications may be complicated by the occurrence of potentially overlapping pathophysiological variants, differences in specific clinical presentations, and commonly associated comorbidities. However, with appropriate long-term management and specialist input, most patients note both symptomatic improvement and functional restoration over time.
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Affiliation(s)
- Lucy Y Lei
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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2
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Parry SW. Should We Ever Pace for Carotid Sinus Syndrome? Front Cardiovasc Med 2020; 7:44. [PMID: 32391383 PMCID: PMC7188762 DOI: 10.3389/fcvm.2020.00044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/06/2020] [Indexed: 12/16/2022] Open
Abstract
Carotid sinus syndrome has been associated with transient loss of consciousness for millennia, and while steeped in cardiovascular lore, there is little in the way of solid evidence to guide its main treatment modality, permanent cardiac pacing. This article reviews the history of the condition in the context of its contemporary understanding before examining three key concepts in the consideration of what constitutes a manageable disease: first, is there a pathophysiologic rationale for the disease (in this case carotid sinus syndrome)? Second, is there a good diagnostic test that will identify it reliably? And finally, is there a convincingly evidence-based treatment for the disease? Relevant literature is reviewed, and recommendations made in how we view pacing in the context of this intriguingly opaque condition.
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Affiliation(s)
- Steve W Parry
- Newcastle University Institute of Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom
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Lacerda GDC, Lorenzo ARD, Tura BR, Santos MCD, Guimarães AEC, Lacerda RCD, Pedrosa RC. Long-Term Mortality in Cardioinhibitory Carotid Sinus Hypersensitivity Patient Cohort. Arq Bras Cardiol 2020; 114:245-253. [PMID: 32215492 PMCID: PMC7077571 DOI: 10.36660/abc.20190008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/15/2019] [Indexed: 11/18/2022] Open
Abstract
Background Cardioinhibitory carotid sinus hypersensitivity (CICSH) is defined as ventricular asystole ≥ 3 seconds in response to 5-10 seconds of carotid sinus massage (CSM). There is a common concern that a prolonged asystole episode could lead to death directly from bradycardia or as a consequence of serious trauma, brain injury or pause-dependent ventricular arrhythmias. Objective To describe total mortality, cardiovascular mortality and trauma-related mortality of a cohort of CICSH patients, and to compare those mortalities with those found in a non-CICSH patient cohort. Methods In 2006, 502 patients ≥ 50 years of age were submitted to CSM. Fifty-two patients (10,4%) were identified with CICSH. Survival of this cohort was compared with that of another cohort of 408 non-CICSH patients using Kaplan-Meier curves. Cox regression was used to examine the relation between CICSH and mortality. The level of statistical significance was set at 0.05. Results After a maximum follow-up of 11.6 years, 29 of the 52 CICSH patients (55.8%) were dead. Cardiovascular mortality, trauma-related mortality and the total mortality rate of this population were not statistically different from that found in 408 patients without CICSH. (Total mortality of CICSH patients 55.8% vs. 49,3% of non-CICSH patients; p: 0.38). Conclusion At the end of follow-up, the 52 CICSH patient cohort had total mortality, cardiovascular mortality and trauma-related mortality similar to that found in 408 patients without CICSH.
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Affiliation(s)
- Gustavo de Castro Lacerda
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brazil1.,Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ - Brazil2
| | - Andrea Rocha de Lorenzo
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brazil1.,Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ - Brazil2
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Gampa A, Upadhyay GA. Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge. J Innov Card Rhythm Manag 2018; 9:3221-3231. [PMID: 32477815 PMCID: PMC7252686 DOI: 10.19102/icrm.2018.090702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 12/11/2017] [Indexed: 11/23/2022] Open
Abstract
Neurocardiogenic syncope is the most frequent cause of syncope in the general population. Many years have been spent on determining an effective treatment for this condition. Conventional treatment usually follows a tiered approach for neurocardiogenic syncope, as follows: first, lifestyle modification, including increased fluid intake and the introduction of physical counterpressure maneuvers, is tried; then the use of targeted pharmacologic therapy, particularly agents that support blood pressure or that drive blood pressure is attempted; and, finally, pacemaker implantation in patients with a predominant cardioinhibitory component to their syncopal episodes is performed. More recently, autonomic modulation with cardiac ganglion ablation has emerged as a promising treatment modality for patients refractory to traditional approaches. In this review, we sought to summarize the existing therapies for neurocardiogenic syncope and explore the latest research on new modalities of treatment.
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Affiliation(s)
- Amulya Gampa
- Department of Internal Medicine, the University of Chicago Medicine, Chicago, IL, USA
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, the University of Chicago Medicine, Chicago, IL, USA
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Gopinathannair R, Salgado BC, Olshansky B. Pacing for Vasovagal Syncope. Arrhythm Electrophysiol Rev 2018; 7:95-102. [PMID: 29967681 PMCID: PMC6020179 DOI: 10.15420/aer.2018.22.2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/03/2018] [Indexed: 12/28/2022] Open
Abstract
Vasovagal syncope (VVS) is due to a common autonomic reflex involving the cardiovascular system. It is associated with bradycardia (cardioinhibitory response) and/or hypotension (vasodepressor response), likely mediated by parasympathetic activation and sympathetic inhibition. While generally a situational, isolated and/or self-limited event, for some, VVS is recurrent, unpredictable and debilitating. Conservative, non-pharmacological management may help, but no specific medical therapy has been proven widely effective. Permanent pacing may have specific benefit, but its value has been debated. The temporal causative association of bradycardia with syncope in those with VVS may help identify which patient could benefit from pacing but the timing and type of pacing in lieu of blood pressure changes may be critical. The mode, rate, pacing algorithm and time to initiate dual-chamber pacing preferentially with respect to the vasovagal reflex may be important to prevent or ameliorate the faint but completely convincing data are not yet available. Based on available data, DDD pacing with the closed loop stimulation algorithm appears a viable, if not the best, alternative presently to prevent recurrent VVS episodes. While several knowledge gaps remain, permanent pacing appears to have a role in managing select patients with VVS.
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Affiliation(s)
| | - Benjamin C Salgado
- Division of Cardiovascular Medicine, University of LouisvilleLouisville, USA
| | - Brian Olshansky
- Mercy Heart and Vascular Institute, Mason City; and the University of Iowa HospitalsIowa City, USA
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6
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Goyal P, Maurer MS. Syncope in older adults. J Geriatr Cardiol 2016; 13:380-6. [PMID: 27594863 PMCID: PMC4984568 DOI: 10.11909/j.issn.1671-5411.2016.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 05/12/2016] [Accepted: 05/19/2016] [Indexed: 12/31/2022] Open
Affiliation(s)
- Parag Goyal
- Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
| | - Mathew S Maurer
- Clinical Cardiovascular Research Lab for the Elderly, Columbia University Medical Center, New York, NY, USA
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Solbiati M, Costantino G, Casazza G, Dipaola F, Galli A, Furlan R, Montano N, Sheldon R. Implantable loop recorder versus conventional diagnostic workup for unexplained recurrent syncope. Cochrane Database Syst Rev 2016; 4:CD011637. [PMID: 27092427 PMCID: PMC8782592 DOI: 10.1002/14651858.cd011637.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The most recent syncope guideline recommends that implantable loop recorders (ILRs) are implanted in the early phase of evaluation of people with recurrent syncope of uncertain origin in the absence of high-risk criteria, and in high-risk patients after a negative evaluation. Observational and case-control studies have shown that loop recorders lead to earlier diagnosis and reduce the rate of unexplained syncopes, justifying their use in clinical practice. However, only randomised clinical trials with an emphasis on a primary outcome of specific ILR-guided diagnosis and therapy, rather than simply electrocardiogram (ECG) diagnosis, might change clinical practice. OBJECTIVES To assess the incidence of mortality, quality of life, adverse events and costs of ILRs versus conventional diagnostic workup in people with unexplained syncope. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2015), MEDLINE, EMBASE, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Search Portal in April 2015. No language restriction was applied. SELECTION CRITERIA We included all randomised controlled trials of adult participants (i.e. ≥ 18 years old) with a diagnosis of unexplained syncope comparing ILR with standard diagnostic workup. DATA COLLECTION AND ANALYSIS Two independent review authors screened titles and abstracts of all potential studies we identified as a result of the literature search, extracted study characteristics and outcome data from included studies and assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We contacted authors of trials for missing data. We analysed dichotomous data (all-cause mortality and aetiologic diagnosis) as risk ratios (RR) with 95% confidence intervals (CI). We used the Chi(2) test to assess statistical heterogeneity (with P < 0.1) and the I² statistic to measure heterogeneity among the trials. We created a 'Summary of findings' table using the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes. MAIN RESULTS We included four trials involving a total of 579 participants. With the limitation that only two studies reported data on mortality and none of them had considered death as a primary endpoint, the meta-analysis showed no evidence of a difference in the risk of long-term mortality between participants who received ILR and those who were managed conventionally at follow-up (RR 0.97, 95% CI 0.41 to 2.30; participants = 255; studies = 2; very low quality evidence) with no evidence of heterogeneity. No data on short term mortality were available. Two studies reported data on adverse events after ILR implant. Due to the lack of data on adverse events in one of the studies' arms, a formal meta-analysis was not performed for this outcome.Data from two trials seemed to show no difference in quality of life, although this finding was not supported by a formal analysis due to the differences in both the scores used and the way the data were reported. Data from two studies seemed to show a trend towards a reduction in syncope relapses after diagnosis in participants implanted with ILR. Cost analyses from two studies showed higher overall mean costs in the ILR group, if the costs incurred by the ILR implant were counted. The mean cost per diagnosis and the mean cost per arrhythmic diagnosis were lower for participants randomised to ILR implant.Participants who underwent ILR implantation experienced higher rates of diagnosis (RR (in favour of ILR) 0.61, 95% CI 0.54 to 0.68; participants = 579; studies = 4; moderate quality evidence), as compared to participants in the standard assessment group, with no evidence of heterogeneity. AUTHORS' CONCLUSIONS Our systematic review shows that there is no evidence that an ILR-based diagnostic strategy reduces long-term mortality as compared to a standard diagnostic assessment (very low quality evidence). No data were available for short-term all-cause mortality. Moderate quality evidence shows that an ILR-based diagnostic strategy increases the rate of aetiologic diagnosis as compared to a standard diagnostic pathway. No conclusive data were available on the other end-points analysed.Further trials evaluating the effect of ILRs in the diagnostic strategy of people with recurrent unexplained syncope are warranted. Future research should focus on the assessment of the ability of ILRs to change clinically relevant outcomes, such as quality of life, syncope relapse and costs.
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Affiliation(s)
- Monica Solbiati
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoDipartimento di Medicina Interna e Specializzazioni MedicheVia Francesco Sforza 35MilanItaly20122
- Università degli Studi di MilanoDipartimento di Scienze Cliniche e di ComunitàVia Francesco Sforza 35MilanMIItaly20122
| | - Giorgio Costantino
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoDipartimento di Medicina Interna e Specializzazioni MedicheVia Francesco Sforza 35MilanItaly20122
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
| | - Franca Dipaola
- Humanitas University ‐ Humanitas Research HospitalDepartment of Biomedical SciencesVia Manzoni 113RozzanoMilanoItaly20089
| | - Andrea Galli
- AO di VimercateEmergency Departmentvia SS Cosma e DamianoVimercateMonza e BrianzaItaly
| | - Raffaello Furlan
- Humanitas University ‐ Humanitas Research HospitalDepartment of Biomedical SciencesVia Manzoni 113RozzanoMilanoItaly20089
| | - Nicola Montano
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoDipartimento di Medicina Interna e Specializzazioni MedicheVia Francesco Sforza 35MilanItaly20122
- Università degli Studi di MilanoDipartimento di Scienze Cliniche e di ComunitàVia Francesco Sforza 35MilanMIItaly20122
| | - Robert Sheldon
- University of CalgaryDepartment of Cardiac Sciences3280 Hospital Drive NWCalgaryABCanadaT2N 4N1
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Kline RJ, Pham K, Labrie-Brown CL, Mancuso K, LeLorier P, Riopelle J, Kaye AD. Postinduction Paced Pulseless Electrical Activity in a Patient With a History of Oropharyngeal Instrumentation-Induced Reflex Circulatory Collapse. Ochsner J 2016; 16:315-320. [PMID: 27660584 PMCID: PMC5024817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Reflex hypotension and bradycardia have been reported to occur following administration of several drugs associated with administration of anesthesia and also following a variety of procedural stimuli. CASE REPORT A 54-year-old postmenopausal female with a history of asystole associated with sedated upper gastrointestinal endoscopy and post-anesthetic-induction tracheal intubation received advanced cardiac resuscitation after insertion of a temporary transvenous pacemaker failed to prevent pulseless electrical activity. The patient's condition stabilized, and she underwent successful cataract extraction, intraocular lens implantation, and pars plana vitrectomy. CONCLUSION Cardiac pacemaker insertion prior to performance of a procedure historically associated with reflex circulatory collapse can be expected to protect a patient from bradycardia but not necessarily hypotension.
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Affiliation(s)
- Ryan J. Kline
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ky Pham
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Carmen L. Labrie-Brown
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ken Mancuso
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Paul LeLorier
- Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans, LA
| | - James Riopelle
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Alan David Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
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Frequent neurally mediated reflex syncope in a young patient with dextrocardia: Efficacy of catheter ablation of the superior vena cava-aorta ganglionated plexus. J Arrhythm 2015; 31:172-6. [PMID: 26336554 DOI: 10.1016/j.joa.2014.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 10/10/2014] [Accepted: 10/17/2014] [Indexed: 11/20/2022] Open
Abstract
Neurally mediated reflex syncope is the most common cause of syncope in young individuals without cardiac or neurological pathology. We report a case of successful catheter ablation in a 17-year-old male with neurally mediated syncope (NMS) of the cardioinhibitory type. The patient had dextrocardia situs inversus totalis with a mirror-image reversal of the thoracic and abdominal organs. Because he experienced multiple syncope episodes despite pharmacological intervention, we performed endocardial ablation of the superior vena cava-aorta ganglionated plexus. Shortly afterwards, his heart rate increased from 40 to 76 beats per minutes. He has not experienced syncope during the 1-year follow-up.
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10
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Kong MH, Winkle RA. When all else fails: take a deep breath, meditate, and assume padmasana. J Interv Card Electrophysiol 2015; 43:103-4. [DOI: 10.1007/s10840-015-0009-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 04/08/2015] [Indexed: 11/24/2022]
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Abstract
The diagnostic process in patients with syncope is not always easy and includes a detailed clinical history, physical examination and baseline electrocardiogram; according to the results of these initial approaches, some additional tests must be performed. Using this strategy, the cause of syncope is diagnosed in 60% to 80% of patients; in the remaining patients, risk stratification can be established to identify those patients at risk of having cardiac events or death at midterm follow-up. This article reviews the treatment of patients with syncope according to the different causes.
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Affiliation(s)
- Angel Moya
- Arrhythmia Unit, Cardiology Department, Vall d'Hebron Hospital, Autonoma University Barcelona, P. Vall d'Hebrón 119 - 129, 08035 Barcelona, Spain.
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12
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Solbiati M, Costantino G, Casazza G, Dipaola F, Galli A, Furlan R, Montano N, Sheldon R. Implantable loop recorder versus conventional diagnostic workup for unexplained recurrent syncope. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Sutton R. Carotid sinus syndrome: Progress in understanding and management. Glob Cardiol Sci Pract 2014; 2014:1-8. [PMID: 25405171 PMCID: PMC4220427 DOI: 10.5339/gcsp.2014.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 05/28/2014] [Indexed: 12/19/2022] Open
Abstract
Carotid sinus syndrome (CSS) is a disease of the autonomic nervous system presenting with syncope, especially in older males who often have cardiovascular disease. The aetiology is unknown and epidemiological data is limited. Forty new patients/million population have been estimated to require pacing for CSS and these patients represent ∼9% of those presenting syncope to a specialist facility. CSS is defined as a response to carotid sinus massage (CSM) that includes reproduction of spontaneous symptoms. Cardioinhibitory CSS shows 3s asystole on CSM and vasodepressor CSS shows >50 mmHg fall in blood pressure (BP), there are mixed forms. The methodology of CSM requires correct massage in the supine and upright with continuous ECG and BP. Assessment of the vasodepressor component implies the ‘method of symptoms’ using atropine to prevent asystole. Carotid sinus hypersensitivity (CSH) is a related condition where CSM is positive in an asymptomatic patient. CSH cannot be assumed to respond to pacing. CSS patients present syncope with little or no warning. If no cause is revealed by the initial evaluation, CSM should be considered in all patients >40 years. CSM carries a small risk of thromboembolism. Therapy for cardioinhibitory CSS is dual chamber pacing, which is most effective in patients with a negative tilt test. Syncope recurrence is ∼20% in 5 years in paced patients. Therapy for the vasodepressor component of CSS, as pure vasodepression or mixed, where tilt testing will likely be positive, is often unrewarding: alternative therapeutic measures may be needed including discontinuation/reduction of hypotensive drugs.
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Affiliation(s)
- Richard Sutton
- Emeritus Professor of Clinical Cardiology, National Heart & Lung Institute, Imperial College, London, UK
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Chen BW, Wang ZG, Lv NQ, Cheng YM, Dang AM. The role of cardiac pacing in carotid sinus syndrome: a meta-analysis. Clin Auton Res 2014; 24:127-34. [PMID: 24682799 DOI: 10.1007/s10286-014-0238-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 03/05/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Cardiac pacing can be used to treat carotid sinus syndrome (CSS), but clinical studies have shown conflicting results. We conducted a systematic review and meta-analysis to evaluate the role of pacing for CSS. METHODS A systematic search of publications in PubMed, Embase, and the Cochrane Library without language restriction was performed. Prospective randomized studies that compared cardiac pacing with standard therapy or pacing with different algorithms were included if the recurrence of syncope or the number of falls was observed. RESULTS Eight studies enrolling 540 patients were identified. In open-label studies, the recurrence of syncope was reduced significantly by cardiac pacing compared with standard therapy. The recurrence of syncope was not different between single- and dual-chamber pacing, but a lower rate of patients with pre-syncope was observed in the group with dual-chamber pacing. Double-blind clinical studies failed to observe the role of cardiac pacing for preventing falls in patients with CSS. CONCLUSION The results of meta-analysis supported the use of cardiac pacing for patients with dominant cardioinhibitory CSS.
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Affiliation(s)
- Bing-Wei Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishilu, Beijing, 100037, People's Republic of China
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Blood pressure regulation X: what happens when the muscle pump is lost? Post-exercise hypotension and syncope. Eur J Appl Physiol 2013; 114:561-78. [PMID: 24197081 DOI: 10.1007/s00421-013-2761-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/22/2013] [Indexed: 01/19/2023]
Abstract
Syncope which occurs suddenly in the setting of recovery from exercise, known as post-exercise syncope, represents a failure of integrative physiology during recovery from exercise. We estimate that between 50 and 80% of healthy individuals will develop pre-syncopal signs and symptoms if subjected to a 15-min head-up tilt following exercise. Post-exercise syncope is most often neurally mediated syncope during recovery from exercise, with a combination of factors associated with post-exercise hypotension and loss of the muscle pump contributing to the onset of the event. One can consider the initiating reduction in blood pressure as the tip of the proverbial iceberg. What is needed is a clear model of what lies under the surface; a model that puts the observational variations in context and provides a rational framework for developing strategic physical or pharmacological countermeasures to ultimately protect cerebral perfusion and avert loss of consciousness. This review summarizes the current mechanistic understanding of post-exercise syncope and attempts to categorize the variation of the physiological processes that arise in multiple exercise settings. Newer investigations into the basic integrative physiology of recovery from exercise provide insight into the mechanisms and potential interventions that could be developed as countermeasures against post-exercise syncope. While physical counter maneuvers designed to engage the muscle pump and augment venous return are often found to be beneficial in preventing a significant drop in blood pressure after exercise, countermeasures that target the respiratory pump and pharmacological countermeasures based on the involvement of histamine receptors show promise.
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Parry SW, Matthews IG. Update on the Role of Pacemaker Therapy in Vasovagal Syncope and Carotid Sinus Syndrome. Prog Cardiovasc Dis 2013; 55:434-42. [DOI: 10.1016/j.pcad.2012.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- A John Camm
- Department of Clinical Sciences, St George's University of London, London SW17 0RE, UK.
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Abstract
Patients commonly present with syncope at emergency departments and other facilities for urgent care. Syncope is understood by physicians to be a transient, self-terminating period of cerebral hypoperfusion that usually results from systemic hypotension, and clinical guidelines for the care of patients with presumed syncope are available. However, the diagnosis and management of such patients continue to pose important diagnostic, therapeutic, and economic challenges, which are the focus of this Review. First, we discuss how to improve symptom characterization to distinguish syncope from other forms of transient loss of consciousness and syncope mimics. Second, we compare methods of risk stratification in patients with suspected syncope, and recommend the introduction of syncope clinics with enhanced interdisciplinary collaboration to optimize patient care at reduced expense. Third, we highlight the importance of the appropriate selection of diagnostic tools and treatment strategies in these syncope clinics. Finally, we address the difficulties associated with therapy for the most-common form of syncope--vasovagal or reflex syncope.
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