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Carotid sinus hypersensitivity is a common cardiovascular cause of unexplained or recurrent falls in older adults. Effective treatment is available once carotid sinus hypersensitivity is identified. Carotid sinus massage is the only practical method for achieving a diagnosis. Carotid sinus massage is contraindicated if a carotid bruit is present.
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... subjects were significantly older, more likely to be female or ex-smokers and had a higher athero- sclerotic co-morbidity (33% ischaemic heart disease; 19% myocardial infarction; 16% stroke) and aspirin or NSAID usage than other unexplained or recurrent fallers ( Table 2). Figure 2 shows the management pathway. Twelve subjects did not or could not attend for carotid Doppler ultrasound. ...
Citations
... In our research, all the patients were evaluated for carotid stenosis through the auscultation of the carotid arteries and a vessels ultrasound in case of carotid bruit. Since no neurological complications occurred, our study confirms that this protocol is safe, in accordance to Richardson et al. [27]. ...
Objective:
to evaluate the safety and tolerability of Tilt Testing (TT) and Carotid Sinus Massage (CSM) in octogenarians with unexplained syncope.
Methods:
patients consecutively referred for transient loss of consciousness to the 'Syncope Units' of three hospitals were enrolled. TT and CSM were performed according to the European Society of Cardiology guidelines on syncope. Complications were evaluated in each group. An early interruption of TT was defined as 'intolerance' and considered as a non-diagnostic response.
Results:
one thousand four hundred and one patients were enrolled (mean age 72 ± 16 years, male 40.8%). Six hundred and ninety-four patients (49.5%) were 80 years old or older (mean age 83 ± 3 years) and 707 (50.5%) were younger (mean age 60 ± 17 years). Complications after TT occurred in 4.5% of older patients and in 2.1% of the younger ones (P = 0.01). All complications were 'minor/moderate', as prolonged hypotension, observed in ∼3% of patients ≥80 years. Major complications such as sustained ventricular tachycardia, ventricular fibrillation, asystole requiring cardiac massage, transient ischaemic attack, stroke and death were not observed in any patient. The presence of orthostatic hypotension and the mean number of syncopal episodes were predictors of TT complications. Intolerance was reported in 2.4% of older patients and 1% of the younger ones (P = 0.08), mainly due to orthostatic intolerance. No complications occurred after CSM.
Conclusions:
TT and CSM appear to be safe and well tolerated in octogenarians, who should not be excluded by age from the diagnostic work-up of syncope.
... Richardson e cols. 14 demonstraram que a MSC pode ser considerada segura mesmo nos pacientes com lesão carotídea documentada pelo duplex scan 14 . Esses autores identificaram 167 pacientes com quedas recorrentes ou inexplicadas e sopro carotídeo. ...
The carotid sinus massage (CSM) is a simple and low-cost technique with many indications.
To determine the safety of CSM in outpatients with high prevalence of atherosclerotic disease and cardiopathy.
A transversal study. Inclusion criteria: Outpatients aged >or= 50 years, referred for ECG. Exclusion criteria: Individuals that refused to participate in a study on the prevalence of the cardioinhibitory response to CSM, patients with dementia, patients with pacemakers, individuals with carotid murmur or history of stroke or AMI in the last three months. The CSM was carried out in the supine position during 10 seconds. The occurrence of sustained arrhythmias or the occurence of neurological deficit during the CSM or in the first 24 hours after its end were considered complications of the CSM.
562 patients were randomly selected from a total of 1,686 individuals that met the inclusion criteria. Sixty individuals met the exclusion criteria. The remaining 502 patients (52% males, 69% with cardiopathies and 50% with atherosclerotic disease) were submitted to 1,053 CSM. Two patients presented complications (0.4%; 95%CI:0%-0.9%). A 71-yr-old man developed left arm monoparesis with complete regression within 30 minutes. Another 56-yr-old man presented left homonymous hemianopsia, with regression after 7 days.
The incidence of CSM-related complications was small, particularly when considering that the population submitted to the maneuver was elderly, with high incidence of structural heart disease and atherosclerotic disease.
... In the patients with stenosis <50%, the maneuver was performed in the usual manner, i.e., in the supine and orthostatic positions during 5 seconds. None of the 121 patients submitted to the CSM developed persistent neurological deficit 14 . ...
FUNDAMENTO: A massagem do seio carotídeo (MSC) é uma técnica simples, de baixo custo e com muitas indicações. OBJETIVO: Determinar a segurança da MSC em pacientes ambulatoriais com alta prevalência de doença aterosclerótica e de cardiopatia. MÉTODOS: Estudo transversal. Critérios de inclusão: pacientes ambulatoriais com idade > 50 anos, encaminhados para realização de eletrocardiograma (ECG). Critérios de exclusão: indivíduos que não aceitaram participar de um estudo sobre a prevalência da resposta cardioinibitória à MSC, pacientes com demência, portadores de marca-passo, indivíduos com sopro carotídeo ou com história de AVC ou IAM nos últimos 3 meses. A MSC foi realizada na posição supina durante 10 segundos. Foram consideradas complicações da MSC a ocorrência de arritmias sustentadas e o aparecimento de déficit neurológico durante a MSC ou nas primeiras 24 horas após o seu término. RESULTADOS: Foram selecionados aleatoriamente 562 pacientes de um total de 1.686 indivíduos com critérios de inclusão. Sessenta indivíduos apresentaram critérios de exclusão. Os 502 pacientes restantes (52% homens, idade média de 65 anos, 69% cardiopatas e 50% com doença aterosclerótica) foram submetidos a 1.053 MSC. Dois pacientes apresentaram complicações (0,4%; IC95%:0%-0,9%). Um homem de 71 anos apresentou monoparesia do braço esquerdo com regressão completa em 30 minutos. Outro homem, de 56 anos, apresentou hemianopsia homônima à esquerda que regrediu em 7 dias. CONCLUSÃO: A incidência de complicações relacionadas à MSC foi pequena, particularmente quando se considerou que a população submetida à manobra era idosa e com alta prevalência de cardiopatia estrutural e de doença aterosclerótica.
... In caso di una stenosi compresa tra il 50% ed il 70% può essere eseguito il massaggio in clinostatismo, ma non in ortostatismo. L'applicazione di questo protocollo ha permesso di eseguire il massaggio in 121 pazienti su 167 (72,5%) che presentavano un soffio carotideo, senza che si verificasse alcun effetto collaterale 29 . ...
... In caso di stenosi significativa (≥ 70%) della arteria carotide comune o interna il massaggio non deve essere eseguito. In caso di una stenosi compresa tra il 50% ed il 70% può essere eseguito il massaggio in clinostatismo, ma non in ortostatismo 20 . Se non viene riprodotta la sincope in concomitanza della bradicardia e/o dell'ipotensione si parla di "ipersensibilità senocarotidea", molto frequente nella popolazione geriatrica. ...
... Hipersensibilidad del seno carotídeo: Puede ser causa de caídas de repetición sin explicación (32) . ...
Este proyecto ha recibido una ayuda de la Consejería de Salud de la Junta de Andalucía (BOJA nº 9 de 15 de enero de 2004; expediente 279/2003), una beca para la realización de proyectos de investigación de la Sociedad Andaluza de Medicina Familiar y Comunitaria –SAMFyC-, junio de 2004 y otra por parte de la Sociedad Española de Medicina Familiar y Comunitaria –SEMFyC-(ayudas a proyectos de tesis doctorales-2006).
This chapter deals with syncope and some of the less common aetiologies, such as psychogenic non‐epileptic attacks. The incidence of the different causes of syncope changes with age. In older patients, reflex syncope, cardiac syncope, and carotid sinus syndrome become increasingly frequent. The usual image of a syncopal attack is of a subject feeling dizzy, going pale, falling with loss of awareness, and then recovering rapidly within about 30 seconds. Training in breath control and anxiety management by physiotherapists and/or clinical psychologists is indicated when the attacks are troublesome. Psychogenic non‐epileptic attacks present for the first time most frequently in teenage or young adult females, but there is increasing recognition that they also present in elderly patients. Episodic events during sleep can be due to normal physiological phenomena and sleep disorders as well as partial or generalised epileptic seizures. Periodic movements become increasingly frequent with age and are very common in the elderly.
Background: In clinical practice, some investigations can have low diagnostic yield or little impact on treatment.
Objectives: This article reviews the impact of asymptomatic carotid artery stenosis on management of syncope, and the role of carotid Doppler ultrasound in carotid sinus syndrome and in syncope. Unclear concepts in syncope workup and management are identified.
Methods: We conducted a clinical survey of 206 internal medicine providers, to explore how many would consider unilateral carotid revascularization to treat isolated syncope, and how many would consider carotid ultrasound in evaluating carotid sinus syndrome. We searched the literature to identify cases in which carotid revascularization improved syncope, and whether or not carotid ultrasound was used to evaluate carotid sinus syndrome. Literature was reviewed for carotid ultrasound use in syncope.
Results: 34% of medical providers surveyed considered carotid endarterectomy for isolated syncope treatment for unilateral high-grade carotid stenosis and 45% of surveyed providers considered carotid ultrasound in evaluating carotid sinus syndrome. The literature revealed older studies of syncope resolution following carotid endarterectomy in patients with specific characteristics; their detailed features are identified here, and revealed that evaluation of carotid sinus syndrome did not require carotid ultrasound. Conclusions: Carotid revascularization is not recommended for unilateral asymptomatic carotid artery stenosis to treat isolated syncope, and carotid ultrasound is not needed in the evaluation of carotid sinus syndrome and rates of neurological complications following carotid sinus massage were low.
This case-based approach to geriatric medicine is suitable for all health professionals and trainees who provide care for the elderly, including interns, residents, geriatric fellows, physicians in practice, and nurse practitioners. Illustrated with more than 40 cases based on the authors' experience in clinical practice, the examples range from the healthy elderly to those with advanced cognitive or physical impairments. Discussions are evidence-based with extensive references, emphasizing differential diagnosis, atypical presentations in late life, age-appropriate medical management, interdisciplinary methods and care in the context of different health care settings. The authors have distilled a wealth of practical and clinical experience in this area to produce a user-friendly guide to geriatric medicine. This is the ideal study guide for certifying examinations and highly suitable as a textbook for courses in geriatric medicine and gerontology. © J. C. Ahronheim, Z.-B. Huang, V. Yen, C. M. Davitt, and D. Barile 2005.
