The effect of carotid massage in older men

Neurally mediated syncope and unexplained or nonaccidental falls in the elderly

Falls and syncope are among the leading causes for which older patients seek hospital admissions. The prevalence of unexplained or nonaccidental falls is high in this group. The clinical spectrum of falls and syncope has been shown to overlap significantly in the elderly. Carotid sinus syndrome and vasovagal syncope, the two common examples of neurally mediated syncope (NMS), have been increasingly recognised as important attributable causes for unexplained falls and syncope. However, in clinical practice NMS is not widely investigated as a cause of fall and is likely to be underdiagnosed.

The heart rate response to carotid artery massage in a sample of healthy elderly people

Carotid artery massage was carried out in a cross-section of 95 healthy elderly subjects (51 men and 44 women, mean age of 74 years) to assess the heart rate response and associated symptoms. These subjects were drawn from a larger group of randomly selected healthy elderly people living in Southampton. They had no history of myocardial infarction or stroke and were not taking any drugs that might enhance the carotid sinus reflex. A continuous distribution of response to carotid artery massage was seen with a median percent change in RR interval of 11.6% (IQR 22.9%); 66% had a percent change in RR interval of < 20%, 90% had a change of < 50%, and 9.5% a change of > 100%. Carotid sinus hypersensitivity (sinus arrest > 3 s) was found in 4 previously asymptomatic subjects; a prevalence of 4.2% (95% CI 1.2%-10.4%), and this was associated with dizziness in 2 of these 4 subjects. Dizziness also occurred in one other subject who had a change in RR interval of 178%. The definition of an abnormal carotid sinus reflex is arbitrary given the continuous RR interval response to carotid artery massage. In diagnosing carotid sinus syndrome, the RR interval response to carotid artery massage alone is not sufficient, as this maneuver must also reproduce the patient's presenting symptoms.

Responses to carotid sinus stimulation before and after propranolol

The response to carotid sinus stimulation was studied in nine elderly men (mean age 67) with no history of cardiac disease, dizziness, or syncope. The response to manual carotid sinus pressure (during one of two studies) was positive (an RR interval of greater than 3s) in three men. But seven men showed positive responses after intravenous propranolol (0.1 mg/kg). Similarly, the RR interval was lengthened by greater than 10 ms/mm Hg in two men during neck suction. Neck suction produced a positive result in four men after intravenous propranolol. The detection of hypersensitivity of the carotid sinus in a high proportion of apparently healthy men, especially during beta blockade, suggests that an abnormal response to carotid sinus massage may not be a reliable indicator for pacemaker treatment.

Value of programmed ventricular stimulation in presumed carotid sinus syndrome

This study determines the results of programmed stimulation in patients with syncope or near-syncope presumed to have the carotid sinus syndrome based on the finding of carotid sinus hypersensitivity and the absence of any other apparent cause for syncope or near-syncope after clinical evaluation. Fourteen patients had coronary artery disease, 1 had dilated cardiomyopathy and 18 patients did not have structural heart disease. Programmed simulation was performed at 2 basic drive cycle lengths and 2 right ventricular sites with 1 to 3 extrastimuli. Sustained unimorphic ventricular tachycardia (VT) was induced in 5 of 15 patients who had structural heart disease, and in none of the 18 patients who did not (p less than 0.05). Polymorphic VT or ventricular fibrillation (VF) was induced in 5 of 15 patients (33%) who had structural heart disease, and in 5 of 18 patients (27%) who did not (p greater than 0.05). Patients who had inducible unimorphic VT were treated with antiarrhythmic drugs that suppressed the induction of VT, and 4 of 5 patients also received a pacemaker; no patient had a recurrence of syncope during follow-up. Patients who had inducible polymorphic VT and VF (n = 10) or no inducible VT (n = 18) received treatment directed at only carotid sinus syndrome. Two patients with inducible VT or VF and 1 patient without inducible VT had recurrent syncope during follow-up, but none had cardiac arrest or died suddenly.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of carotid sinus stimulation to exercise testing

This review is an attempt to demonstrate the safety and usefulness of the simple maneuver of carotid sinus stimulation with selected subjects undergoing exercise tests. In a variety of circumstances the addition of CSP before or after treadmill walking can yield clinically relevant information relating to arrhythmias, conduction disturbances, symptoms, and pacemakers. Further applications and benefits of these combined procedures remain to be clarified and expanded for judicious application with attention to safeguards.

Differential response to carotid sinus pressure during sinus rhythm and atrial fibrillation

In a patient who presented with syncope and palpitation left carotid sinus massage resulted in prolonged ventricular asystole during atrial fibrillation. In the same patient left carotid sinus stimulation during sinus rhythm produced no change in sinus rate and only slight PR interval prolongation. This very different response may be the result of factors which are relevant only during atrial fibrillation such as an increase in the atrial depolarisation frequency and a prolongation of the duration of the atrioventricular nodal concealment zone secondary to increased vagal activity. An increase in atrioventricular nodal refractoriness could not explain this differential response.

Carotid sinus reflex in patients undergoing coronary angiography: relationship of degree and location of coronary artery disease to response to carotid sinus massage

Heart rate and blood pressure responses during and after carotid sinus massage were examined in 66 patients just before coronary angiography. A significant relationship was found between heart rate and blood pressure responses and (1) angina pectoris class, (2) total coronary artery disease score and (3) presence of high-grade (> 90%) stenosis of any of the three major coronary arteries. Only patients with contraction abnormalities of the anterolateral left ventricular region had greater cardionhibitory responses than patients with normal left ventricular angiograms. Among patients with normal left ventricular angiograms, those with more than 50% stenosis of one or more vessels had significantly (p < 0.01) greater responses than those with no or minimal coronary artery disease. All 21 hypersensitive (asystole longer than 3 seconds) patients had significant multivessel coronary artery stenoses or single-vessel high-grade stenosis (greater than or equal to 90%) proximal to the atrioventricular nodal artery. None of the 11 patients with normal coronary arteries had an exaggerated response to carotid sinus massage. These data support the association of an exaggerated response to carotid sinus massage in the presence of symptomatic coronary artery disease and suggest that the magnitude of response is influenced by the severity of the disease.