Pacing as a Treatment for Reflex-Mediated (Vasovagal, Situational, or Carotid Sinus Hypersensitivity) Syncope: A Systematic Review for the 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Open accessAbstract
Objectives To determine, using systematic review of the biomedical literature, whether pacing reduces risk of recurrent syncope and relevant clinical outcomes among adult patients with reflex-mediated syncope.Methods MEDLINE (through PubMed), EMBASE, and the Cochrane Central Register of Controlled Trials (through October 7, 2015) were searched for randomized trials and observational studies examining pacing and syncope, and the bibliographies of known systematic reviews were also examined. Studies were rejected for poor-quality study methods and for the lack of the population, intervention, comparator, or outcome(s) of interest.Results Of 3,188 citations reviewed, 10 studies met the inclusion criteria for systematic review, including a total of 676 patients. These included 9 randomized trials and 1 observational study. Of the 10 studies, 4 addressed patients with carotid sinus hypersensitivity, and the remaining 6 addressed vasovagal syncope. Among the 6 open-label (unblinded) studies, we found that pacing was associated with a 70% reduction in recurrent syncope (relative risk [RR]: 0.30; 95% confidence interval [CI]: 0.15-0.60). When the 2 analyzable studies with double-blinded methodology were considered separately, there was no clear benefit (RR: 0.73; 95% CI: 0.25-2.1), but confidence intervals were wide. The strongest evidence was from the randomized, double-blinded ISSUE-3 (Third International Study on Syncope of Uncertain Etiology) trial, which demonstrated a benefit of pacing among patients with recurrent syncope and asystole documented by implantable loop recorder.Conclusions There are limited data with substantive evidence of outcome ascertainment bias, and only 2 studies with a double-blinded study design have been conducted. The evidence does not support the use of pacing for reflex-mediated syncope beyond patients with recurrent vasovagal syncope and asystole documented by implantable loop recorder.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The recommendation in Section 5.2 was based on a separately commissioned systematic review of the available evidence.
“As noted in Section 1.1, the recommendation in this section was based on a separately commissioned systematic review of the available evidence, the results of which were used to frame our decision making. Full details are provided in the ERC’s systematic review report (9).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [9]
Although syncope occurs in patients with POTS, it is relatively infrequent, and there is little evidence that the syncope is due to POTS.
“Although syncope occurs in patients with POTS, it is relatively infrequent, and there is little evidence that the syncope is due to POTS (9,10).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary (2017) · cites this paper as [10]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.
(2009) · PubMed Central · Cited by 44,859 · see citing works
The Cochrane Collaboration's tool for assessing risk of bias in randomised trials
Higgins, J. P. T., Altman, D. G., Gotzsche, P. C., Juni, P., Moher, D., Oxman, A. D., Savovic, J., Schulz, K. F., Weeks, L., Sterne, J. A. C., et al. (2011) · BMJ · doi:10.1136/bmj.d5928 · Cited by 33,817 · see citing works
Conducting Meta-Analyses in <i>R</i> with the <b>metafor</b> Package
Viechtbauer, W. (2010) · Journal of Statistical Software · doi:10.18637/jss.v036.i03 · Cited by 20,464 · see citing works
Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2009.06.005 · Cited by 19,575 · see citing works
(2014) · Medical Entomology and Zoology · Cited by 17,633 · see citing works
Sheldon, R. S., Grubb, B. P., Olshansky, B., Shen, W.-K., Calkins, H., Brignole, M., Raj, S. R., Krahn, A. D., Morillo, C. A., Stewart, J. M., et al. (2015) · Heart Rhythm · doi:10.1016/j.hrthm.2015.03.029 · Cited by 1,013 · see citing works
Ottawa Hospital Research Institute
Bouhassira, E. E. (2015) · Sage eBooks · doi:10.4135/9781483347660.n335 · Cited by 851 · see citing works
Connolly, S. J., Sheldon, R., Thorpe, K. E., Roberts, R. S., Ellenbogen, K. A., Wilkoff, B. L., Morillo, C., Gent, M., & for the VPS II Investigators (2003) · JAMA · doi:10.1001/jama.289.17.2224 · Cited by 500 · see citing works
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.03.004 · Cited by 484 · see citing works
The North American vasovagal pacemaker study (VPS)
Connolly, S., Sheldon, R., Roberts, R., & Gent, M. (1999) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(98)00549-x · Cited by 474 · see citing works
Brignole, M., Menozzi, C., Moya, A., Andresen, D., Blanc, J. J., Krahn, A. D., Wieling, W., Beiras, X., Deharo, J. C., Russo, V., et al. (2012) · Circulation · doi:10.1161/circulationaha.111.082313 · Cited by 437 · see citing works
Sutton, R., Brignole, M., Menozzi, C., Raviele, A., Alboni, P., Giani, P., & Moya, A. (2000) · Circulation · doi:10.1161/01.cir.102.3.294 · Cited by 407 · see citing works
GANZEBOOM, K. S., MAIRUHU, G., REITSMA, J. B., LINZER, M., WIELING, W., & VAN DIJK, N. (2006) · Journal of Cardiovascular Electrophysiology · doi:10.1111/j.1540-8167.2006.00595.x · Cited by 375 · see citing works
Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE)
Kenny, R. A. M., Richardson, D. A., Steen, N., Bexton, R. S., Shaw, F. E., & Bond, J. (2001) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(01)01537-6 · Cited by 344 · see citing works
RAVIELE, A., GIADA, F., MENOZZI, C., SPECA, G., ORAZI, S., GASPARINI, G., SUTTON, R., & BRIGNOLE, M. (2004) · European Heart Journal · doi:10.1016/j.ehj.2004.06.031 · Cited by 323 · see citing works
Vasovagal syncope in medical students and their first-degree relatives
Serletis, A., Rose, S., Sheldon, A. G., & Sheldon, R. S. (2006) · European Heart Journal · doi:10.1093/eurheartj/ehl147 · Cited by 229 · see citing works
Long-term outcome of paced and nonpaced patients with severe carotid sinus syndrome
Brignole, M., Menozzi, C., Lolli, G., Bottoni, N., & Gaggioli, G. (1992) · The American Journal of Cardiology · doi:10.1016/0002-9149(92)90860-2 · Cited by 210 · see citing works
ACCF/AHA Clinical Practice Guideline Methodology Summit Report
Jacobs, A. K., Kushner, F. G., Ettinger, S. M., Guyton, R. A., Anderson, J. L., Ohman, E. M., Albert, N. M., Antman, E. M., Arnett, D. K., Bertolet, M., et al. (2013) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2012.09.025 · Cited by 175 · see citing works
A controlled trial of acute and long-term medical therapy in tilt-induced neurolly mediated syncope
Brignole, M., Menozzi, C., Gianfranchi, L., LOLLI, G., Bottoni, N., & Oddone, D. (1992) · The American Journal of Cardiology · doi:10.1016/0002-9149(92)90615-6 · Cited by 172 · see citing works
The expectation effect and cardiac pacing for refractory vasovagal syncope
Sud, S., Massel, D., Klein, G. J., Leong-Sit, P., Yee, R., Skanes, A. C., Gula, L. J., & Krahn, A. D. (2007) · The American Journal of Medicine · doi:10.1016/j.amjmed.2006.05.046 · Cited by 151 · see citing works
Carotid sinus syndrome, should we pace? A multicentre, randomised control trial (Safepace 2)
Ryan, D. J., Nick, S., Colette, S. M., & Roseanne, K. (2010) · Heart · doi:10.1136/hrt.2009.176206 · Cited by 91 · see citing works
Claesson, J.-E., Kristensson, B.-E., Edvardsson, N., & Wahrborg, P. (2007) · Europace · doi:10.1093/europace/eum180 · Cited by 89 · see citing works
Russo, V., Rago, A., Papa, A. A., Golino, P., Calabrò, R., Russo, M. G., & Nigro, G. (2013) · Heart · doi:10.1136/heartjnl-2013-303878 · Cited by 59 · see citing works
FLAMMANG, D. (1999) · EP Europace · doi:10.1053/eupc.1998.0021 · Cited by 34 · see citing works
Who das really benefit by the permanent cardiac pacing in cardiodepressive vasovagal syncope
Lelonek, M., & Goch, J. H. (1999) · Clinical and Experimental Medical Letters · Cited by 5 · see citing works
Flagged first, then by citations
Research works printed but not linked: 1
- [18]18. Romme J.J.C.M., Reitsma J.B., Black C.N. et al: Drugs and pacemakers for vasovagal, carotid sinus and situational syncope (Review). : The Cochrane Collaboration, Published in the Cochrane Library 2013. Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0016226/. Accessed March 1, 2017. Google Scholar
Cited by
Sorted by citations
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Circulation · doi:10.1161/cir.0000000000000498 · Cited by 408 · see citing works
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.03.003 · Cited by 327 · see citing works
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.03.002 · Cited by 155 · see citing works
ACC/AHA/HRS Versus ESC Guidelines for the Diagnosis and Management of Syncope
Goldberger, Z. D., Petek, B. J., Brignole, M., Shen, W.-K., Sheldon, R. S., Solbiati, M., Deharo, J.-C., Moya, A., & Hamdan, M. H. (2019) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2019.09.012 · Cited by 82 · see citing works
Levine, G. N., O’Gara, P. T., Beckman, J. A., Al‐Khatib, S. M., Birtcher, K. K., Cigarroa, J. E., Fuentes, L. D. L., Deswal, A. M., Fleisher, L. A., Gentile, F., et al. (2019) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2019.02.012 · Cited by 63 · see citing works
Canadian Cardiovascular Society Clinical Practice Update on the Assessment and Management of Syncope
Sandhu, R. K., Raj, S. R., Thiruganasambandamoorthy, V., Kaul, P., Morillo, C. A., Krahn, A. D., Guzmán, J. C., Sheldon, R. S., Banijamali, H. S., Macintyre, C. J., et al. (2020) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2019.12.023 · Cited by 42 · see citing works
Self-citationGopinathannair, R., Salgado, B. C., & Olshansky, B. (2018) · Arrhythmia & Electrophysiology Review · doi:10.15420/aer.2018.22.2 · Cited by 32 · see citing works
Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge
Gampa, A., & Upadhyay, G. A. (2018) · Journal of Innovations in Cardiac Rhythm Management · doi:10.19102/icrm.2018.090702 · Cited by 10 · see citing works
Cunha, G., Rocha, B. M. L., Gomes, R. V., Silva, B. V., Mendes, G., Morais, R., Araújo, I., & Fonseca, C. (2019) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.13790 · Cited by 9 · see citing works
Etiology, risk factors, and prognosis of patients with syncope: A single‐center analysis
Ling, L., Feng, T., Xue, X., & Ling, Z. (2021) · Annals of Noninvasive Electrocardiology · doi:10.1111/anec.12891 · Cited by 8 · see citing works
Should We Ever Pace for Carotid Sinus Syndrome?
Parry, S. W. (2020) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2020.00044 · Cited by 5 · see citing works
Певзнер, А. В., Kuchinskaya, Е. А., Киктев, В. Г., & Иосифович, Х. Г. (2021) · Rational Pharmacotherapy in Cardiology · doi:10.20996/1819-6446-2021-04-09 · Cited by 2 · see citing works
Recurrent syncope resulting from large carotid atheroma
Vanam, S., Chindhy, S., Han, F. T., & Shen, J. (2020) · HeartRhythm Case Reports · doi:10.1016/j.hrcr.2020.11.014 · Cited by 2 · see citing works
Update on Cardiac Pacing in Reflex Syncope
Lee, J. Z., & Shen, W.-K. (2020) · Springer eBooks · doi:10.1007/978-3-030-44507-2_24 · Cited by 1 · see citing works
Lacerda, G. D. C., Lorenzo, A. D., Tura, B. R., dos Santos, M. C., Guimarães, A. E. C., de Lacerda, R. C., & Pedrosa, R. C. (2019) · Arquivos Brasileiros de Cardiologia · doi:10.36660/abc.20190008 · Cited by 1 · see citing works
Yang, S., & ZIMETBAUM, P. J. (2020) · Springer eBooks · doi:10.1007/978-3-030-47868-1_26 · Cited by 1 · see citing works
Editorial commentary: To pace, or not to pace in vasovagal syncope?
Morita, H. (2018) · Trends in Cardiovascular Medicine · doi:10.1016/j.tcm.2018.06.005
A Moving Anecdote: Exercise-Induced Vasovagal Sinus Arrest
Aliwaiai, M., Caceres-Figueroa, P. P., & Munoz, F. D. (2018) · The American Journal of Medicine · doi:10.1016/j.amjmed.2018.11.009
Schwindel bei kardiologischen Erkrankungen
Jilek, C., & Lewalter, T. (2019) · DMW - Deutsche Medizinische Wochenschrift · doi:10.1055/a-0799-2451
Guzmán, A. K. R., Mercado, K. Y. M., Mieses, M. M. J., & Peralta, R. A. R. (2021) · Ciencia y Salud · doi:10.22206/cysa.2021.v5i1.pp97-107
Yang, S., & ZIMETBAUM, P. J. (2022) · Springer eBooks · doi:10.1007/978-3-030-88953-1_4
59-Year-Old Woman With Recurrent Syncope
Stanko, K. M., Dumais, M. G., & Cullen, M. W. (2025) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2024.06.017
Reflex Syncope and the Role of Cardiac Pacing: A Systematic Review and Meta-Analysis
Collin, C., & Solano, J. (2025) · Cureus · doi:10.7759/cureus.91874
Electrophysiology procedures for preventing falls in older people living in the community
Gibson, K., Priest, L., Masoli, J. A. H., Naganathan, V., Ganesan, A., & Dyer, S. M. (2026) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd016363
- Authors
- Varosy, P. D., Chen, L. Y., Miller, A. L., Noseworthy, P. A., Slotwiner, D. J., & Thiruganasambandamoorthy, V.
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2017-08
- Volume
- 70
- Issue
- 5
- Pages
- 664-679
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W3023455871
- Cited by
- 24
- References
- 25
- Citations by year
- 2026: 1 · 2025: 2 · 2022: 1 · 2021: 3 · 2020: 5 · 2019: 5 · 2018: 4 · 2017: 3
- FWCI
- 0.99
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- cardiac pacing, vasovagal syncope, carotid sinus hypersensitivity, situational syncope, recurrent syncope, asystole, implantable loop recorder
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
