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FAINTING Causes and Ways to Minimize Risk Roy Sauberman, MD  FACC Summit Medical Group
[object Object],Wayne HH:  Am J Med  1961;30:418-38
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
People faint for many reasons ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997 2 Gendelman HE, et al. NY State J Med 1983 3 Day SC, et al, AM J of Med 1982 4 Kapoor W. Evaluation and outcome of patients with syncope.  Medicine 1990;69:160-175
EXPLAINED 60% UNEXPLAINED 60% 40%
Cardiac? Non-Cardiac?
Prognosis ,[object Object],[object Object],[object Object],[object Object],Kapoor WN, et al:  N Engl J Med  1983;309:197-204
[object Object],[object Object],[object Object],[object Object],[object Object],Soteriades ES, Evans JC, Larson MG, et al.:   N Engl J Med  2002;347(12):878-85
A Diagnostic Plan is Essential Modified after ESC Syncope Task Force, 2004
[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
Cardiovascular Causes Common   Denominator Transient Global Cerebral Hypoperfusion
Cardiovascular Causes Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Aortic Stenosis HCM Pulmonary HTN Aortic   Dissection Neurally- Mediated  Reflex 60% 15% 10% 5%
Cardiovascular Causes Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Aortic Stenosis HCM Pulmonary HTN Aortic   Dissection Neurally- Mediated  Reflex Unexplained Causes = Approximately 10% 60% 15% 10% 5%
[object Object],[object Object],[object Object],[object Object],Neurologic Causes
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Other Causes
History and Physical Exam Surface ECG Neurological Testing • Head CT Scan • Carotid Doppler • MRI • Skull Films • Brain Scan • EEG CV Syncope Workup • Holter • ELR • Tilt Table • Echo • EP Testing Other CV Testing • Angiogram • Exercise Test • SAECG Psychological Evaluation ENT Evaluation Endocrine Evaluation
Elements of Initial Examination ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],Kapoor WN, et al:  N  Engl J Med  1983;309:197-204
[object Object],[object Object],[object Object],[object Object],Kapoor WN, et al:  N  Engl J Med  1983;309:197-204
Carotid Sinus Massage (CSM) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cardiovascular Causes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Cardiovascular Causes
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Cardiovascular Causes
Echocardiography ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Echocardiography
A AORTIC STENOSIS HYPERTROPHIC CARDIOMYOPATHY
 
No Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al  N Eng J Med,  1983. 2 Kapoor,  Am J Med , 1991. 3 Linzer, et al.  Ann Int. Med , 1997. 4 Kapoor,  Medicine , 1990. 5 Kapoor,  JAMA , 1992 6 Krahn,  Circulation , 1995 7 Krahn,  Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
Tilt Table Testing
Tilt Table Testing
Vasovagal Syncope “ Common Faint”  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Tilt Table Testing ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Vasovagal Syncope “ Common Faint”
+/- Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al  N Eng J Med,  1983. 2 Kapoor,  Am J Med , 1991. 3 Linzer, et al.  Ann Int. Med , 1997. 4 Kapoor,  Medicine , 1990. 5 Kapoor,  JAMA , 1992 6 Krahn,  Circulation , 1995 7 Krahn,  Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1% * 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Arrhythmias
Diagnostic Gold Standard for Arrhythmias ECG strip recorded during clinical symptoms ECG Monitoring
ECG Monitoring   Selected Use Based on Initial Examination and Risk Stratification ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Telemetry Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hospital Telemetry
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ambulatory ECG Monitoring
ECG Monitoring Options ILR MCOT External Loop Recorder Event   Recorder Holter Monitor 12-Lead 2 Days 7 Days 30+ Days 36 Months 10 Seconds ILR = insertable loop recorder MCOT= mobile cardiac outpatient telemetry
Mobile Cardiac Outpatient Telemetry  (MCOT) Patient Indicates symptoms on PDA. Abnormal ECG transmitted automatically PDA   or   cell phone stores ECG data and symptom status. Wireless transmission capability provided.  Monitor center receives, reviews and transmits data to physician.  Pre-determined ‘urgency’ criteria determine timing of physician alerts Physician  receives and acts upon data as medically appropriate
 
 
Implantable Loop Recorder • Battery longevity up to 36 months • Gold standard (symptom – rhythm correlation) • High diagnostic yield for patients with infrequent events • High patient compliance
 
 
 
Krahn,  Circ.  1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and  clinical assessment) Rhythm strip useful in diagnosis  of 132 patients (64%) 206 Patients with  Syncope Diagnostic Yield
64% Diagnostic Yield Krahn,  Circ.  1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and  clinical assessment) Rhythm strip useful in diagnosis  of 132 patients (64%) 206 Patients with  Syncope Diagnostic Yield
ILR Advantages • The less frequent the symptoms are . . . – The less likely conventional testing will yield a diagnosis – The more testing will be required – The more costly the attempts to diagnose will be – The longer the diagnostic process – The more frustrated the patient and clinician become – The more likely the patient may be in harm’s way • Breaks the costly & time consuming diagnostic cycle
 
“ Those who suffer from frequent and   severe fainting often die suddenly.” Hippocrates, 1000 BC
MicroVolt T Wave Alternans (MTWA) Even Beats Odd Beats Mean V alt V alt
Mechanism Linking MTWA to Ventricular Arrhythmias Long APD  Short APD  Long APD  Short APD Action Potential Alternans Leads to T-Wave Alternans Long APD Region Short APD Region Spatially Discordant Alternans Leads to Dispersion of Recovery, Wave Front Fractionation, and Reentry
MicroVolt T Wave Alternans Testing
 
Reduction of noise through adaptive  cancellation of artifact LL (Segment) LL Impedance Respiration LL (Center) LL Enhanced Noise Reduction
 
Ikeda, et al.: Am J Cardiol 2002; 89:79-82 Post-MI CHF Klingenheben, et al.: Lancet 2000;356:651-52 Syncope Bloomfield, et al.: Circulation 1999;100:1-508
Gold, et al.: J Am Coll Cardiol 2000;36:2247-53
Candidates for  MicroVolt T Wave Alternans Testing ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Ambulatory ECG Monitoring MTWA Testing ,[object Object]
Clues Suggesting Possible  Malignant Arrhythmias ,[object Object],[object Object],[object Object],[object Object],[object Object]
Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al  N Eng J Med,  1983. 2 Kapoor,  Am J Med , 1991. 3 Linzer, et al.  Ann Int. Med , 1997. 4 Kapoor,  Medicine , 1990. 5 Kapoor,  JAMA , 1992 6 Krahn,  Circulation , 1995 7 Krahn,  Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
Electrophysiologic Testing ,[object Object]
 
Intracardiac Recordings PA = Intra-atrial Conduction Interval  A = Atrial Electrical Activity AH = Atria-His Bundle Conduction Interval  H = His Bundle Electrical Activity HV = His Bundle-Ventricle Conduction Interval  V = Ventricular Electrical Activity Surface ECG High Right  Atrium IEGM His Bundle IEGM CS IEGM RV Apex IEGM PR Basic Sinus Cycle Length QRS A V V
Predictors for Abnormal EP Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
EP Study Diagnoses ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Sudden Death Risk High Coronary  Risk Post M I Heart Failure/ EF < 35%) Previous  VF / VT Syncope  / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)
Sudden Death Risk High Coronary  Risk Post M I Heart Failure/ EF < 35%) Previous  VF / VT Syncope  / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)
[object Object],[object Object],[object Object],[object Object],[object Object],Epidemic of SCD in the US 1 Circulation . 2001;104:2158-2163. 2  Myerburg RJ, Castellanos A.  Cardiac Arrest and Sudden Cardiac Death, in Braunwald E, Zipes DP, Libby P,  Heart Disease, A textbook of Cardiovascular Medicine . 6 th  ed. 2001. W.B. Saunders, Co.
Leading Causes of Death in the US 1  National Vital Statistics Report ,  Vol 49 (11), Oct. 12, 2001 2   MMWR . State-specific mortality from sudden  cardiac death – US 1999.Feb 15,  2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers
Leading Causes of Death in the US 1  National Vital Statistics Report ,  Vol 49 (11), Oct. 12, 2001 2   MMWR . State-specific mortality from sudden  cardiac death – US 1999.Feb 15,  2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers Only ALL cancers combined cause more deaths each year than  sudden cardiac arrest!!
 
Sudden Cardiac Arrest ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
 
 
 
www.fainting.com
 
 

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Fainting: Causes and Ways to Minimize Risk

  • 1. FAINTING Causes and Ways to Minimize Risk Roy Sauberman, MD FACC Summit Medical Group
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  • 5. 1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997 2 Gendelman HE, et al. NY State J Med 1983 3 Day SC, et al, AM J of Med 1982 4 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175
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  • 10. A Diagnostic Plan is Essential Modified after ESC Syncope Task Force, 2004
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  • 13. Cardiovascular Causes Common Denominator Transient Global Cerebral Hypoperfusion
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  • 18. History and Physical Exam Surface ECG Neurological Testing • Head CT Scan • Carotid Doppler • MRI • Skull Films • Brain Scan • EEG CV Syncope Workup • Holter • ELR • Tilt Table • Echo • EP Testing Other CV Testing • Angiogram • Exercise Test • SAECG Psychological Evaluation ENT Evaluation Endocrine Evaluation
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  • 28. A AORTIC STENOSIS HYPERTROPHIC CARDIOMYOPATHY
  • 29.  
  • 30. No Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
  • 33.
  • 34.
  • 35.
  • 36. +/- Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1% * 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
  • 37.
  • 38. Diagnostic Gold Standard for Arrhythmias ECG strip recorded during clinical symptoms ECG Monitoring
  • 39.
  • 40.
  • 42.
  • 43. ECG Monitoring Options ILR MCOT External Loop Recorder Event Recorder Holter Monitor 12-Lead 2 Days 7 Days 30+ Days 36 Months 10 Seconds ILR = insertable loop recorder MCOT= mobile cardiac outpatient telemetry
  • 44. Mobile Cardiac Outpatient Telemetry (MCOT) Patient Indicates symptoms on PDA. Abnormal ECG transmitted automatically PDA or cell phone stores ECG data and symptom status. Wireless transmission capability provided. Monitor center receives, reviews and transmits data to physician. Pre-determined ‘urgency’ criteria determine timing of physician alerts Physician receives and acts upon data as medically appropriate
  • 45.  
  • 46.  
  • 47. Implantable Loop Recorder • Battery longevity up to 36 months • Gold standard (symptom – rhythm correlation) • High diagnostic yield for patients with infrequent events • High patient compliance
  • 48.  
  • 49.  
  • 50.  
  • 51. Krahn, Circ. 1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and clinical assessment) Rhythm strip useful in diagnosis of 132 patients (64%) 206 Patients with Syncope Diagnostic Yield
  • 52. 64% Diagnostic Yield Krahn, Circ. 1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and clinical assessment) Rhythm strip useful in diagnosis of 132 patients (64%) 206 Patients with Syncope Diagnostic Yield
  • 53. ILR Advantages • The less frequent the symptoms are . . . – The less likely conventional testing will yield a diagnosis – The more testing will be required – The more costly the attempts to diagnose will be – The longer the diagnostic process – The more frustrated the patient and clinician become – The more likely the patient may be in harm’s way • Breaks the costly & time consuming diagnostic cycle
  • 54.  
  • 55. “ Those who suffer from frequent and severe fainting often die suddenly.” Hippocrates, 1000 BC
  • 56. MicroVolt T Wave Alternans (MTWA) Even Beats Odd Beats Mean V alt V alt
  • 57. Mechanism Linking MTWA to Ventricular Arrhythmias Long APD Short APD Long APD Short APD Action Potential Alternans Leads to T-Wave Alternans Long APD Region Short APD Region Spatially Discordant Alternans Leads to Dispersion of Recovery, Wave Front Fractionation, and Reentry
  • 58. MicroVolt T Wave Alternans Testing
  • 59.  
  • 60. Reduction of noise through adaptive cancellation of artifact LL (Segment) LL Impedance Respiration LL (Center) LL Enhanced Noise Reduction
  • 61.  
  • 62. Ikeda, et al.: Am J Cardiol 2002; 89:79-82 Post-MI CHF Klingenheben, et al.: Lancet 2000;356:651-52 Syncope Bloomfield, et al.: Circulation 1999;100:1-508
  • 63. Gold, et al.: J Am Coll Cardiol 2000;36:2247-53
  • 64.
  • 65.
  • 66.
  • 67. Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
  • 68.
  • 69.  
  • 70. Intracardiac Recordings PA = Intra-atrial Conduction Interval A = Atrial Electrical Activity AH = Atria-His Bundle Conduction Interval H = His Bundle Electrical Activity HV = His Bundle-Ventricle Conduction Interval V = Ventricular Electrical Activity Surface ECG High Right Atrium IEGM His Bundle IEGM CS IEGM RV Apex IEGM PR Basic Sinus Cycle Length QRS A V V
  • 71.
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  • 73.  
  • 74. Sudden Death Risk High Coronary Risk Post M I Heart Failure/ EF < 35%) Previous VF / VT Syncope / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)
  • 75. Sudden Death Risk High Coronary Risk Post M I Heart Failure/ EF < 35%) Previous VF / VT Syncope / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)
  • 76.
  • 77. Leading Causes of Death in the US 1 National Vital Statistics Report , Vol 49 (11), Oct. 12, 2001 2 MMWR . State-specific mortality from sudden cardiac death – US 1999.Feb 15, 2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers
  • 78. Leading Causes of Death in the US 1 National Vital Statistics Report , Vol 49 (11), Oct. 12, 2001 2 MMWR . State-specific mortality from sudden cardiac death – US 1999.Feb 15, 2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers Only ALL cancers combined cause more deaths each year than sudden cardiac arrest!!
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Editor's Notes

  1. Transient Loss of Consciousness, or TLOC, is just that—as is illustrated here. It can be as simple as a benign ‘faint’ or a symptom of an underlying disease that may lead to sudden death. Or it may not be syncope at all.
  2. This slide provides a simple classification of the principal causes of syncope. This scheme lists the causes of syncope from the most commonly observed (Left) to the least common (Right). This ranking may be helpful in thinking about the strategy for evaluating syncope in individual patients. Within the boxes,the most common causes of syncope are indicated for each of the major diagnostic groups. VVS—Vasovagal Syncope CSS—Carotid Sinus Syndrome ANS—Autonomic Nervous System HCM—Hypertrophic Cardiomyopathy
  3. This slide provides a simple classification of the principal causes of syncope. This scheme lists the causes of syncope from the most commonly observed (Left) to the least common (Right). This ranking may be helpful in thinking about the strategy for evaluating syncope in individual patients. Within the boxes,the most common causes of syncope are indicated for each of the major diagnostic groups. VVS—Vasovagal Syncope CSS—Carotid Sinus Syndrome ANS—Autonomic Nervous System HCM—Hypertrophic Cardiomyopathy
  4. WPW—Wolff Parkinson White syndrome HCM—Hypertrophic Cardiomyopathy
  5. Carotid sinus massage (CSM) is an often overlooked, yet highly cost effective test, especially in older syncope patients. CSM must be applied with care, and the method described here has proven both safe and effective. Note that an abnormal response to CSM (i.e., Carotid Sinus Hypersensitivity, CSH) is not diagnostic of Carotid Sinus Syndrome (CSS). Reproduction of symptoms is a crucial diagnostic element. To achieve symptom reproduction, it may be useful to conduct CSM with the patient in the upright posture. If the latter is to be done, the patient should be safely secured to a tilt-table in order to prevent injury from a fall. Note: May perform during tilt-table test. *Munro N, McIntosh S, Lawson J, et al. Incidence of complications after carotid sinus massage in older patients with syncope. J Am Geriatr Soc . 1994;42:1248-1251.