Clinical context and outcome of carotid sinus syndrome diagnosed by means of the ‘method of symptoms’
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AIMS: The prevalence and outcome of carotid sinus syndrome (CSS) reported in the literature vary owing to differences in indications and methods of carotid sinus massage (CSM). METHODS AND RESULTS: We performed CSM on all patients aged 40 years and above with unexplained syncope after the initial evaluation. Carotid sinus massage was performed in the supine and standing positions on both sides for 10 s during continuous electrocardiogram and blood pressure monitoring; CSS was diagnosed in the event of an abnormal response to CSM in association with reproduction of spontaneous symptoms ('method of symptoms'). From July 2005 to July 2012, CSS was found in 164 (8.8%) of 1855 patients (mean age 77 ± 9 years, 73% males): 81% had an asystolic reflex (mean pause 7.6 ± 2.2 s) and 19% a vasodepressor reflex (mean lowest systolic blood pressure 65 ± 15 mmHg). Potential multifactorial causes of syncope (orthostatic hypotension, bundle branch block, bradycardia, tachyarrhythmias) were found in 74% of patients. One hundred forty-one patients received the proper care [advice on lifestyle measures in all, discontinuation (#40) or reduction (#17) of antihypertensive drugs, pacemaker implantation (#57)] and were followed up for 39 ± 25 months. Syncope recurred in 23 patients; the actuarial syncopal recurrence rate was 7% at 1 year and 26% at 5 years. Total syncopal episodes decreased from 91 per year during the 2 years before evaluation to 21 episodes per year during follow-up (P = 0.001). On Cox proportional-hazards regression, a mixed or vasodepressor response to tilt testing was the only independent predictor of syncopal recurrence (hazard ratio = 1.8; P = 0.01). CONCLUSION: Carotid sinus massage by means of the 'method of symptoms' indentifies a clinical syndrome with definite features and outcome. A treatment strategy involving lifestyle measures, reduction of antihypertensive drugs and cardiac pacing when appropriate is effective in reducing the syncopal recurrence rate.
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The diagnosis of carotid sinus syndrome requires both the reproduction of spontaneous symptoms during carotid sinus massage and clinical features of spontaneous syncope compatible with a reflex mechanism.
“There is strong consensus that the diagnosis of CSS requires both the reproduction of spontaneous symptoms during CSM and clinical features of spontaneous syncope compatible with a reflex mechanism.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [92]
The Methods state that, under the ‘method of symptoms,’ CSS was diagnosed when carotid sinus massage reproduced spontaneous syncope or pre-syncope in the presence of carotid sinus hypersensitivity; the Discussion likewise says symptom reproduction is required. Our copy does not state that clinical features of spontaneous syncope compatible with a reflex mechanism are an additional requirement. The Results also include 14 diagnosed patients who had pre-syncope only. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe prevalence of carotid sinus syndrome, as defined here, was 8.8% when carotid sinus massage was performed after the initial evaluation in 1855 consecutive patients older than 40 years of age with syncope compatible with a reflex mechanism.
“The prevalence of CSS, as defined here, was 8.8% when CSM was performed after the initial evaluation in 1855 consecutive patients >40 years of age with syncope compatible with a reflex mechanism. 92,93”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [92]
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Self-citation
- Authors
- Solari, D., Maggi, R., Oddone, D., Solano, A., Croci, F., Donateo, P., & Brignole, M.
- Affiliations
- Presidio Ospedaliero (IT)
- Corresponding author
- Brignole, M.
- Venue
- Europace
- Publisher
- Oxford University Press (OUP)
- Published
- 2013-09-20
- Volume
- 16
- Issue
- 6
- Pages
- 928-934
- ISSN
- 1099-5129 (ISSN-L)
- 1532-2092
- OpenAlex
- W2101644914
- Cited by
- 52
- References
- 24
- Citations by year
- 2026: 5 · 2025: 2 · 2024: 3 · 2023: 2 · 2022: 4 · 2021: 4 · 2020: 6 · 2019: 2 · 2018: 6 · 2017: 4 · 2016: 3 · 2015: 5 · 2014: 5 · 2013: 1
- FWCI
- 4.60
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- EP Europace (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cerebrovascular and Carotid Artery Diseases
- Keywords
- carotid sinus syndrome, carotid sinus massage, syncope, pacemaker implantation, antihypertensive medication reduction, orthostatic hypotension, bundle branch block, bradycardia, tachyarrhythmias, tilt table test
- MeSH terms
- Aged, Carotid Artery Diseases, Female, Humans, Italy, Male, Prognosis, Sensitivity and Specificity, Syndrome, Reproducibility of Results, Prevalence, Risk Assessment, Tilt-Table Test, Syncope, Vasovagal, Symptom Assessment
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