Diagnostic yield and development of a neurocardiovascular investigation unit for older adults in a district hospital

BACKGROUND: Dizziness, syncope, and falls are common occurrences in elderly people. Neurocardiovascular investigation units aim to detect those patients who fall due to disturbances of blood pressure control or cardiac conduction. Specialist units have a high diagnostic yield in the investigation of these problems. Does this translate to less specialized centers? We report on the diagnostic findings of a district general hospital neurocardiovascular investigation unit. METHOD: A total of 120 consecutive patients over the age of 65 presenting to a single geriatrician were assessed. After a full history and physical examination, patients underwent neurocardiovascular investigation: blood pressure and heart rate response to active stand, carotid sinus massage, and 30-minute head-up tilt. RESULTS: The 120 patients assessed had a mean age of 78 years (range 66-94 years); in this group, 85 were women. Of these patients, 23% presented with falls, 14% with blackouts, and 30% with dizziness. The remaining 33% had overlap of symptoms. Neurocardiovascular investigations produced a diagnosis in 57% of the patients: 22% had cardioinhibitory carotid sinus syndrome (CSS): 15% had vasodepressor CSS; 29% had orthostatic hypotension; and 3% had vasovagal syncope. Thirteen percent had more than one neurocardiovascular abnormality, and 18% had benign positional vertigo. Five patients had postural instability causing falls. Hyperventilation syndrome, aortic stenosis, dysrhythmia, cervical spondylosis, and epilepsy each accounted for one case. Seventeen percent of the subjects remained undiagnosed after integrated neurocardiovascular assessment. CONCLUSION: Management of falls requires access to neurocardiovascular assessment. It is feasible to provide such a service in the district general hospital setting, with a comparable diagnostic yield to tertiary referral centers.     

The usefulness of carotid sinus massage in different patient groups

AIM: to determine the positive yield of carotid sinus massage in different patient groups: unexplained syncope, falls, dizziness and controls. DESIGN: observational study. SETTING: teaching hospital. METHODS: we studied consecutive patients over the age of 60 years referred to the 'falls clinic' with a history of unexplained syncope, unexplained falls and unexplained dizziness. We also studied asymptomatic control subjects recruited from a general practice register aged 60 years and over. All patients and control subjects underwent a full clinical assessment (comprehensive history and detailed clinical examination including supine and erect blood pressure measurements) and 12-lead electrocardiography. We performed carotid sinus massage in the supine position for 5 seconds separately on both sides followed by repeating the procedure in the upright positions using a motorised tilt table. Heart rate and blood pressure were recorded using a cardiac monitor and digital plethysmography respectively. The test was considered positive if carotid sinus massage produced asystole with more than a 3 second pause (cardioinhibitory type of carotid sinus syndrome), or a fall in systolic blood pressure of more than 50 mmHg in the absence of significant cardioinhibition (vasodepressor type of carotid sinus syndrome) or where there was evidence of both vasodepressor and cardio-inhibition as above (mixed type). RESULTS: we studied 44 asymptomatic control subjects and 221 symptomatic patients (130 with unexplained syncope, 41 with unexplained falls and 50 with unexplained dizziness). In the overall symptomatic patient group, the positive yield (any type of carotid sinus syndrome) was 17.6% (95% CI = 12.7-22.5). The positive yield in men (26.3% (95% CI = 16.4-36.2)) was twice that in women (13.1% (95% CI = 7.6-18.6)) (P = 0.014). Overall any type of carotid sinus syndrome was present in 22.3% (n = 29) of the syncope group, 17.1% (n = 7) in the unexplained fallers group and 6% (n = 3) in the dizziness group. We also found that no women with unexplained dizziness had a positive carotid sinus massage test. None of the controls demonstrated a positive response. None of the subjects suffered any complications during or after the test. CONCLUSION: the positive yield of carotid sinus massage in symptomatic patients was 17.6% with the yield in men being twice that in women. None of the asymptomatic control subjects demonstrated a positive response. The yields in unexplained syncope and unexplained falls patients were around 4-fold and 3-fold higher respectively than in unexplained dizziness patients. The positive yield in women with unexplained dizziness (without a definite history of syncope and falls) is zero. Hence, carotid sinus massage in older adults should particularly be targeted at patients with unexplained syncope and unexplained falls.     

Complications of carotid sinus massage--a prospective series of older patients

BACKGROUND: there is a causal association between carotid sinus hypersensitivity, falls and syncope in elderly subjects. Neurological complications during carotid sinus massage have been reported in case studies and two retrospective series. Our aim was prospectively to ascertain the incidence of complications occurring after carotid sinus massage performed for diagnostic purposes in a consecutive series of patients. METHODS: 1000 consecutive subjects aged 50 years or over who attended the accident and emergency department with syncope or 'unexplained' falls had carotid sinus massage. Carotid sinus massage was performed for 5 s on the right and then left sides both supine and upright (70 degrees head-up tilt) with continuous heart rate and phasic blood pressure recording. Contraindications to carotid sinus massage were the presence of a carotid bruit, recent history of stroke or myocardial infarction or previous ventricular tachyarrhythmia. RESULTS: complications occurred in nine patients immediately after cessation of carotid sinus massage. Eight had transient neurological complications possibly attributable to carotid sinus massage: visual disturbance, 'pins and needles' and sensation of finger numbness in two cases each, leg weakness in one and sensation of 'being drunk' in one. All transient complications resolved within 24 h. In one patient mild weakness of the right hand persisted. CONCLUSIONS: no subjects had cardiac complications and 1% had possible neurological symptoms, which resolved in most cases. Persistent neurological complications are uncommon, occurring in 1:1000 patients (0.1%) or 1: 3805 episodes of carotid sinus massage (0.03%).     

Carotid sinus hypersensitivity in asymptomatic older persons: implications for diagnosis of syncope and falls

BACKGROUND: Carotid sinus hypersensitivity is the most commonly reported cause of falls and syncope in older persons. Recent guidelines recommend 5 to 10 seconds of carotid sinus massage in supine and upright positions with beat-to-beat monitoring. The aim of this study was to determine the prevalence of carotid sinus hypersensitivity in (1) an unselected community sample of older people and (2) a subsample with no history of syncope, dizziness, or falls using recently standardized diagnostic criteria. METHODS: One thousand individuals older than 65 years were randomly sampled from a single general practice register; 272 participants underwent supine and upright carotid sinus massage with continuous heart rate and phasic blood pressure monitoring. Carotid sinus hypersensitivity was defined as asystole of 3 seconds or greater and/or a drop in systolic blood pressure of 50 mm Hg or greater. RESULTS: Carotid sinus hypersensitivity was present in 107 individuals (39%); 24% had asystole of 3 seconds or greater during carotid sinus massage; and 16% had symptoms (including syncope) with carotid sinus hypersensitivity. Age (odds ratio, 1.05; 95% confidence interval, 1.00-1.09) and male sex (odds ratio, 1.71; 95% confidence intervals, 1.04-2.82) were the only predictors of carotid sinus hypersensitivity. In 80 previously asymptomatic individuals, carotid sinus hypersensitivity was present in 28 (35%) and accompanied by symptoms in 10. The 95th percentile for carotid sinus massage response was 7.3 seconds' asystole and a 77-mm Hg drop in systolic blood pressure. CONCLUSIONS: Carotid sinus hypersensitivity is common in older persons, even those with no history of syncope, dizziness, or falls. The finding of a hypersensitive response should not necessarily preclude further investigation for other causes of syncope.     

The use of an implantable loop recorder in the investigation of unexplained syncope in older people

INTRODUCTION: Reveal is a patient activated implantable loop recorder device with an 18 month battery life now available to assist in the diagnosis of suspected syncope or arrhythmias. We present our experience using this device in older subjects referred to a dedicated falls and syncope clinic in whom usual clinical assessment had not satisfactorily identified an attributable diagnosis but where we still suspected a cardiovascular cause for syncope or falls. METHODS AND RESULTS: during the past 3 years 15 subjects (mean age 73 years, range 61-89 years) had Reveal implanted for symptoms of syncope alone (n=6; 40%) and unexplained falls (n=3; 20%) or symptoms of syncope and unexplained falls (n=6; 40%). Symptom duration was long (mean 48 months; range 4-200 months). Subjects had experienced significant morbidity, 6 subjects (40%) required A&E attendance or hospital admission and 4 (27%) experienced a fracture. Despite extensive and repeated investigations, which included 12-lead ECG, echocardiogram, 24-h ambulatory heart rate monitor, 24-h ambulatory blood pressure monitor, orthostatic blood pressure measurement, supine and erect carotid sinus massage, electroencephalogram, and passive and GTN head up tilt testing, the attributable diagnosis remained unexplained. Of the 15 subjects, 7 have activated the device at 4 (range 0-14) months after implantation. Bradycardia was identified in 3 and ventricular tachycardia in 1 subject. Two subjects did not activate the device during the 18 months it was in-situ. Four people had problems with device activation. This is comparable to rates noted using Reveal in younger subjects. CONCLUSION: Reveal offers additional diagnostic yield in complex elderly subjects with suspected cardiovascular causes of syncope or unexplained falls which have not been previously satisfactorily diagnosed despite extensive investigations.     

Amnesia for loss of consciousness in carotid sinus syndrome: implications for presentation with falls

OBJECTIVES: The goal of this study was to compare the clinical characteristics of patients with carotid sinus syndrome who presented with falls with those who presented with syncope. BACKGROUND: Carotid sinus syndrome presents with both falls and syncope. The reasons for this differential presentation are unknown, but amnesia for loss of consciousness may be the underlying cause. METHODS: Two groups of 34 consecutive patients with carotid sinus syndrome as the sole cause of falls and syncope were recruited. Cognitive function and clinical characteristics were compared between the two groups. RESULTS: Syncopal subjects with carotid sinus syndrome were more likely to be older males (18 [53%] vs. 7 [21%] years; p = 0.006) with a longer duration of symptoms (27.9 vs. 13.3 months; p = 0.009) and more soft tissue injuries (19 [56%] vs. 9 [26%]; p = 0.03). Duration of asystole during carotid sinus massage was similar in both groups (5.1 vs. 5.4 s; p = 0.42), but witnessed amnesia for loss of consciousness was more frequent in fallers than those with syncope (21 [95%] vs. 4 [12%]; p < 0.001). Clinical characteristics and cognitive function were otherwise similar in both groups. CONCLUSIONS: Patients with carotid sinus syndrome have similar rates of witnessed loss of consciousness during laboratory testing regardless of symptoms. However, those presenting with falls are far less likely to perceive any disturbance of consciousness than those with syncope, showing for the first time the manner in which such patients manifest symptoms. Cognitive impairment does not explain the amnesia for loss of consciousness seen in fallers with carotid sinus syndrome.     

A high diagnostic rate in older patients attending an integrated syncope clinic

OBJECTIVES: To describe the findings in the first year of an integrated syncope clinic for older patients and to review the published literature on "integrated" syncope clinics investigating older people. DESIGN: Review of syncope clinic database and Medline search for relevant literature. SETTING: Outpatient syncope clinics in two district hospitals in the same city. PARTICIPANTS: Secondary referrals from the in- and outpatient population with recurrent unexplained presyncopal and syncopal symptoms. RESULTS: The results of testing in 76 patients over the age of 60 years were available for analysis. A diagnosis was achieved in 67 (88%) of the patients with 76% of the diagnoses being cardiovascular in origin. The prevalence rates of neurocardiogenic syncope (32%) and carotid sinus syndrome (17%), however, differed from previously reported rates. CONCLUSIONS: Evaluation of presyncopal and syncopal events in an "integrated syncope clinic" achieves a high diagnostic yield in older subjects.     

Carotid sinus syndrome--clinical characteristics in elderly patients.

Carotid sinus massage was carried out on 130 consecutive patients referred for investigation of dizziness, syncope or unexplained falls. Carotid sinus syndrome was diagnosed in 33 for whom no other cause of symptoms was identified. Right-sided hypersensitivity was more frequent than left-sided. Thirty per cent identified a prodrome before syncope and 30% had retrograde amnesia for the event. In 52%, symptoms were precipitated by head movement and in 48% by vagal stimuli. Seven described 'drop attacks' but symptoms were reproduced with carotid sinus massage during head-up tilt. Injuries, including fractured neck of femur, were sustained by the majority. Carotid sinus massage should be performed routinely on all elderly patients who have symptoms of unexplained dizziness, falls or syncope. Cardiac pacing relieves syncopal symptoms in those with a predominant cardio-inhibitory response and recurrent syncope.     

Syncope clinics and the older adult

Syncope is a common condition, with an overlap of falls and syncope experienced more commonly in the older adult. Admission for syncope work-up should occur in certain circumstances such as syncope resulting in traumatic injury or where a strong suspicion of cardiac syncope arises. However, the majority of individuals presenting with an episode of syncope do not require admission and a dedicated syncope clinic in an outpatient setting has been shown to be beneficial. This should provide readily available testing such as Head-up tilt table testing and carotid sinus massage as well as access to cardiac and neurology services should they be required.     

Prevalence of hypotensive disorders in older patients with a pacemaker in situ who attend the Accident and Emergency Department because of falls or syncope.

AIMS: To ascertain the proportion of adults with a pacemaker in situ attending the Accident and Emergency Department because of syncope or unexplained falls and the cause of index symptoms in these patients, including the prevalence of hypotensive syndromes. METHODS AND RESULTS: Patients presenting to the Accident and Emergency Department with unexplained syncope or non-accidental falls, who had a pacemaker in situ, were studied. Eligible patients had cardiovascular assessment (morning orthostatic blood pressure measurement, heart rate and BP measurements during carotid sinus stimulation (supine and upright), head-up tilt at 70 degrees for 40 min), assessment of haemodynamics during fixed mode pacing and gait and balance assessment. Of 5863 patients screened, 13.5% had unexplained syncope or a non-accidental fall; of these only 3% (26 patients) had pacemakers in situ. Of 18 study patients (82 +/- 8 years), 10 were female. Sixteen had a hypotensive diagnosis. Seven had more than one attributable hypotensive diagnosis. Five of 13 with vasodepressor carotid sinus syndrome had no previous diagnosis of carotid sinus hypersensitivity. No patients had vasovagal syncope induced during passive head-up tilt testing. CONCLUSION: It is rare for patients who attend the Accident and Emergency Department because of syncope or unexplained falls to have a pacemaker in situ. In those who do, hypotensive disorders are a common finding.     

Diagnosis of carotid sinus hypersensitivity in older adults: carotid sinus massage in the upright position is essential

OBJECTIVE—To assess the diagnostic value of supine and upright carotid sinus massage in elderly patients.
DESIGN—Prospective controlled cohort study.
SETTING—Three inner city accident and emergency departments and a dedicated syncope facility.
PATIENTS—1375 consecutive patients aged > 55 years presenting with unexplained syncope and drop attacks; 25 healthy controls.
INTERVENTIONS—Bilateral supine carotid sinus massage, repeated in the 70° head up tilt position if the initial supine test was not diagnostic of cardioinhibitory and mixed carotid sinus hypersensitivity.
MAIN OUTCOME MEASURES—Diagnosis of cardioinhibitory or mixed carotid sinus hypersensitivity; clinical characteristics of supine v upright positive groups.
RESULTS—226 patients were excluded for contraindications to carotid sinus massage. Of 1149 patients undergoing massage, 223 (19%) had cardioinhibitory or mixed carotid sinus hypersensitivity; 70 (31%) of these had a positive response to massage with head up tilt following negative supine massage (95% confidence interval, 25.3% to 37.5%). None of the healthy controls showed carotid sinus hypersensitivity on erect or supine massage. The initially positive supine test had 74% specificity and 100% sensitivity; these were both 100% for the upright positive test. The clinical characteristics of the supine v upright positive subgroups were similar.
CONCLUSIONS—The diagnosis of carotid sinus hypersensitivity amenable to treatment by pacing may be missed in one third of cases if only supine massage is performed. Massage should be done routinely in the head up tilt position if the initial supine test is negative.


Keywords: carotid sinus; tilt table testing; syncope; elderly patients     

Carotid sinus hypersensitivity--a modifiable risk factor for fractured neck of femur.

BACKGROUND: the potential impact on morbidity, mortality and health care economics makes it important to identify patients at risk of fracture, in particular fractured neck of femur (FNOF). Older patients with carotid sinus hypersensitivity (CSH) are more likely to have unexplained falls and to experience fractures, particularly FNOF. Our objective was to determine the prevalence of CSH in patients with FNOF. DESIGN: case-controlled prospective series. METHODS: consecutive cases were admissions over 65 years with FNOF. Controls were consecutive patients admitted for elective hip surgery, frail elderly people admitted to hospital medical wards and day-hospital patients. All patients had a clinical assessment of cognitive function, physical abilities and history of previous syncope, falls and dizziness, in addition to repeated carotid sinus massage with continuous heart rate and phasic blood pressure measurement. RESULTS: heart rate slowing and fall in systolic blood pressure was greater for patients with FNOF than those admitted for elective hip surgery (P < 0.05 and P < 0.001). CSH was present in 36% of the FNOF group, none of the elective surgery group, 13% of the acutely ill controls and 17% of the outpatients. It was more likely to be present in FNOF patients with a previous history of unexplained falls or an unexplained fall causing the index fracture. The heart rate and systolic blood pressure responses to carotid sinus stimulation were reproducible. CONCLUSION: older patients with an acute neck of femur fracture who do not give a clear history of an accidental fall or who have had previously unexplained falls are likely to have CSH. CSH may be a modifiable risk factor for older patients at risk of hip fracture.     

Pacing interventions for falls and syncope in the elderly

There is a high prevalence of cardiovascular disorders among elderly patients with recurrent falls or syncope, and cardiovascular causes are implicated in a significant proportion of three cases. Common cardiovascular causes of falls and syncope include carotid sinus syndrome, vasovagal episodes, sick sinus syndrome, and atrioventricular block. A comprehensive history and physical examination supplemented by electrocardiographic monitoring, carotid sinus massage, and tilt-table testing in appropriately selected patients form the basis of the diagnostic evaluation to exclude a significant cardiovascular disorder. Patients with documented symptomatic bradycardia often benefit from pacemaker implantation, as evidenced by a reduction in recurrent events and improved quality of life. Although dual-chamber pacemakers, particularly those with rate responsiveness, provide more physiologic pacing than single-chamber ventricular devices, the superiority of dual-chamber pacemakers in reducing major clinical events has not been demonstrated. The efficacy of an aggressive evaluation and patient-management strategy that includes pacemaker implantation for elderly patients with recurrent falls has been validated only by one prospective clinical trial; however, available data are compelling. For a variety of cardiovascular conditions, permanent pacemaker implantation has a demonstrated efficacy to prevent symptoms that arise from transient hypotension and decreased cerebral perfusion. The implication of these data is that many falls may be preventable through permanent pacemaker implantation in appropriately selected patients.     

Diagnostic utility of mechanical, pharmacological and orthostatic stimulation of the carotid sinus in patients with unexplained syncope.

OBJECTIVES: The purpose of the present study was to systematically evaluate the diagnostic utility of mechanical, pharmacological and orthostatic stimulation of the carotid sinus in a consecutive series of patients with recurrent unexplained syncope. BACKGROUND: Carotid sinus hypersensitivity (CSH) is an infrequently recognized cause of recurrent unexplained syncope usually diagnosed by carotid sinus massage (CSM) in the supine position. The diagnostic utility of systematic assessment of mechanical, pharmacological and orthostatic stimulation of the carotid sinus has not been clearly established. METHODS: Eighty consecutive patients (63 +/- 12 years) with a history of recurrent unexplained syncope (mean episodes: 6 +/- 3); 30 age-matched controls (65 +/- 14 years) and 16 patients (59 +/- 12 years) with syncope not related to CSH were studied. Pharmacological stimulation of the carotid sinus was achieved by randomly administering bolus injections of nitroprusside and phenylephrine. Mechanical stimulation of the carotid sinus was performed by CSM applied for 5 s in the supine position and after 2 min at 60 degrees. A 60 degree low-dose isoproterenol head-up tilt test (HUTT) was also performed for a total duration of 30 min. RESULTS: Carotid sinus hypersensitivity was elicited by CSM in the supine position in seven (8.7%) patients, two (6.6%) controls and one (6.3%) patient with syncope unrelated to CSH, compared with 48 (60%) patients, two (6.6%) controls and one (6.3%) syncope unrelated to CSH patient after 60 degree HUTT, increasing the diagnostic yield by 51%. Baroreceptor gain was significantly reduced in the CSH group. Head-up tilt test was positive in 12 (25%) patients with CSH, two (6.6%) controls and two (12%) with documented syncope but not positive in any of the patients in which syncope remained unexplained. Diagnostic accuracy was enhanced by 38% (31% supine vs. 69% upright) when CSM was performed at 60 degrees. CONCLUSIONS: CSH was documented in 68% of patients, 8.7% in the supine position and 60% in the upright position. Sensitivity was increased by 51%, and diagnostic accuracy was enhanced by 38% by performing CSM in the upright position. Decreased baroreceptor gain was documented and may play a role in the pathophysiology of CSH.     

Syncope in the elderly: new trends in diagnostic approach and nonpharmacologic management

Syncope in the elderly is an important health care issue because of the large patient population, challenging diagnostic and therapeutic approaches, and potentially devastating consequences. Significant comorbidity and atypical clinical presentations render a precise determination of the cause of syncope difficult. Recent studies suggest that noninvasive tests, such as carotid sinus massage or tilt-table testing, can be helpful in the diagnostic workup. It has been shown that permanent pacemaker therapy benefits elderly patients with carotid sinus hypersensitivity, and younger patients with recurrent vasovagal syncope. The implantable wireless loop recorder can be effective in documenting transient arrhythmias as causes of syncope in selected patients. Elderly patients with syncope and a low ejection fraction are at increased risk of sudden death due to malignant ventricular arrhythmia. Electrophysiologic study and electrophysiology-guided therapy should be considered in this segment of the population.     

The prevalence of Neurally Mediated Syncope in older patients presenting with unexplained falls

AimsTo determine the prevalence and clinical significance of carotid sinus syndrome (CSS) and vasovagal syncope (VVS), the two common types of Neurally Mediated Syncope (NMS), in a cohort of older patients with unexplained falls.MethodsPatients presenting with unexplained and accidental falls were identified from 200 consecutive admissions of falls in patients aged 65 years and older admitted to the Rapid Assessment Medical Unit (RAMU) in a teaching hospital. A sample of unexplained and accidental fallers underwent carotid sinus massage (CSM) and tilt table testing (TTT) as per a standardised protocol. Baseline characteristics, clinical variables and the prevalence of NMS were compared between the two groups.ResultsFalls were unexplained in 26% of patients. The prevalence of NMS was 24% (5/21) among patients with unexplained falls who underwent assessment for NMS, whereas it was nil (0/17) in patients with accidental falls (P = 0.050). The prevalence of previous falls was significantly higher in patients with unexplained falls (P = 0.0025), but all other baseline characteristics were similar between the two groups.ConclusionFalls are unexplained in a significant number of older patients presenting to acute hospitals. The assessment of unexplained fallers for NMS is clinically important as this may be aetiologically related in nearly a quarter of these patients.     

A study of carotid sinus massage and head-up tilt table testing in patients with syncope and near-syncope

Patients with syncope of unknown origin are commonly evaluated using several diagnostic tools. It has been suggested that there is a significant overlap between the results of head-up tilt table testing (HUT) and carotid sinus massage (CSM). We retrospectively studied the association between tilt table test results and CSM outcome in 136 patients with syncope or near-syncope who underwent both tests. Carotid sinus massage was performed prior to the tilt test, with the patient supine. The patient was then tilted to 60 degrees for up to 30 minutes. If this did not elicit a symptomatic abnormal hemodynamic response, the tilt was repeated for up to 30 minutes with intravenous isoproterenol. An abnormal response on HUT was elicited in 18% of patients and carotid sinus syndrome was diagnosed in 13%. Mild carotid sinus sensitivity was seen in 14%. Both tests were positive in 4 patients (3%; 11% of patients with a positive test). There was no significant relationship between HUT outcome and CSM result (p = 0.03). Patients with an abnormal CSM result were older (p < 0.001) and more likely to have prior cardiovascular diagnoses (p = 0.01). The opposite applied to patients with abnormal HUT (p = 0.02 and p = 0.0048, respectively). In conclusion, we did not find a concordance between HUT and CSM outcomes in patients with syncope or near-syncope of undetermined origin.     

The application of a standardized strategy of evaluation in patients with syncope referred to three syncope units.

BACKGROUND: The appropriate diagnostic work-up of patients with syncope is not well defined. We applied the guidelines of Italian 'Associazione Nazionale Medici Cardiologi Ospedalieri' to a group of consecutive patients with syncope referred to three Syncope Units. The aim of the study was to evaluate the applicability of those guidelines in the 'real world' and their impact on the use of the tests. METHODS: We evaluated 308 consecutive patients with syncope (mean age 61 +/- 20 years; median of three syncopal episodes per patient). The hierarchy and appropriateness of diagnostic tests and the definitions of the final diagnosis followed standardized predefined criteria. In brief, all patients underwent initial evaluation consisting of history, physical examination, supine and upright blood pressure measurement and standard electrocardiogram (ECG) (only in patients > 45 years or with history of heart disease). Any subsequent investigations were based on the findings of the initial evaluation. Priority was given to cardiological tests (prolonged ECG monitoring, exercise test, electrophysiological study), or to neurally mediated tests (carotid sinus massage, tilt test, ATP test), or to neuro-psychiatric tests, as appropriate. FINDINGS: The initial evaluation alone was diagnostic in 72 patients (23%). One further test was necessary for diagnosis in 65 patients (21%), > or = 2 tests in 64 (21%) and > or = 3 tests in 50 (16%). The diagnostic yield was 10% for ECG, 3% for echocardiogram, 16% for Holter, 5% for exercise test, 27% for electrophysiological study, 57% for carotid sinus massage, 52% for tilt testing and 15% for ATP test. At the end of the work-up the mechanism of syncope remained unexplained in 57 patients (18%). CONCLUSIONS: When standardized criteria based on the appropriateness of indications are used, few simple tests are usually needed for diagnosis of syncope.     

Cardioinhibitory carotid sinus hypersensitivity predicts an asystolic mechanism of spontaneous neurally mediated syncope.

AIMS: We correlated the finding of cardioinhibitory carotid sinus hypersensitivity (CSH) with that observed during a spontaneous syncopal relapse by means of an implantable loop recorder (ILR). METHODS AND RESULTS: We included 18 consecutive patients with suspected recurrent neurally mediated syncope and positive cardioinhibitory response during carotid sinus massage (max pause 5.5 +/- 1.6 s) who had subsequent documentation of a spontaneous syncope by means of an ILR. They were compared with a 2:1 age- and sex-matched group of 36 patients with a clinical diagnosis of recurrent neurally mediated syncope and negative response to carotid sinus massage, tilt testing and ATP test. Asystole >3 s was observed at the time of the spontaneous syncope in 16 (89%) of 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; during 35 +/- 22 months of follow-up, 2 syncopal episodes recurred in 2 patients (14%), and pre-syncope occurred in another 2 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). CONCLUSIONS: In patients with suspected neurally mediated syncope, the finding of cardioinhibitory CSH predicts an asystolic mechanism at the time of spontaneous syncope and, consequently, suggests a possible benefit of cardiac pacing therapy.     

Syncope

Syncope, which can be defined as a transient loss of consciousness caused by transient global cerebral hypoperfusion and characterised by rapid onset, short duration, and spontaneous complete recovery, is a common condition. This definition is useful for differentiating syncope from other clinical conditions that also involve real or apparent transient loss of consciousness, but in which the mechanism is not global cerebral hypoperfusion, such as epilepsy, falls, or psychiatric pseudosyncope. We reviewed the etiological classification of syncope and found that reflex syncope is the most common etiology in the general population, with a good prognosis, whereas cardiac syncope increases with age and has a worse prognosis. We also reviewed the role and limitations of different tests, specifically referring to the interpretation of the results of carotid sinus massage, the role of tilt-table testing, the diagnostic strategy in patients with syncope and bundle branch block, the adenosine test, and the emerging role of prolonged electrocardiographic monitoring. Furthermore, we reviewed the different therapeutic options available. The importance of establishing syncope units with the aim of improving the diagnostic process and optimizing resources is also emphasized. Full English text available from:www.revespcardiol.org.