J. Lawson

Clinical characteristics of vasodepressor, cardioinhibitory, and mixed carotid sinus syndrome in the elderly

PURPOSE Carotid sinus syndrome (CSS) is frequently overlooked as a cause of syncope in the elderly. It is diagnosed when carotid sinus massage (CSM) produces asystole exceeding 3 seconds (cardioinhibitory CSS), a reduction in systolic blood pressure exceeding 50 mm Hg independent of heart rate slowing (vasodepressor CSS), or a combination of the two (mixed CSS). Most published data pertain to the cardioinhibitory subtype. The recent availability of noninvasive phasic blood pressure monitoring has allowed accurate routine assessment of the vasodepressor response to CSM. The aim of this study was to assess the clinical characteristics of vasodepressor, cardioinhibitory, and mixed CSS. PATIENTS AND METHODS CSM was carried out on 132 consecutive patients over 65 years referred for investigation of dizziness, falls, or syncope. Massage was performed both supine and upright with continuous electrocardiographic and phasic blood pressure monitoring. Patients exhibiting greater than 1.5-second asystole were given 600 micrograms of intravenous atropine to abolish heart rate slowing and allow assessment of the pure vasodepressor response. RESULTS Carotid sinus hypersensitivity was documented in 64 patients (mean age 81 +/- 7 years, 31 male). The response was vasodepressor in 37%, cardioinhibitory in 29%, and mixed in 34%. Thirty-six patients had recurrent syncope, 17 presented with unexplained falls, and the remainder had dizziness alone. Symptoms had been present for a median of 24 months, and the median number of syncopal episodes was four. Twenty-five percent had sustained a fracture and, of these, 93% had not experienced a prodrome. Head movement precipitated symptoms in 47% and vagal stimuli in 73%. Episodes were unwitnessed in two thirds of patients. Twelve patients who presented with falls denied syncope but had witnessed loss of consciousness during CSM. Mean cardioinhibition was 5 +/- 2 seconds and mean vasodepression 61 +/- 9 mm Hg. The blood pressure nadir occurred rapidly at 18 +/- 3 seconds after massage, and baseline values were regained at 30 +/- 6 seconds. The clinical characteristics of patients with vasodepressor, cardioinhibitory, and mixed responses were similar. CONCLUSION CSS is an underdiagnosed cause of dizziness, falls, and syncope in the elderly. The vasodepressor form occurs more frequently than previously reported and has clinical characteristics similar to those of the cardioinhibitory and mixed subtypes. Elderly patients with this condition may deny syncope and present with recurrent unexplained falls. CSM, ideally with noninvasive phasic blood pressure monitoring, should be routinely performed in elderly patients with unexplained bradycardic or hypotensive symptoms.

Diagnosis of Geriatric Patients with Severe Dizziness

OBJECTIVE: To identify the causes of dizziness in older patients presenting to the general practitioner and the clinical characteristics at presentation that might guide the general practitioner to the likely cause of dizziness and the most appropriate specialty for subsequent referral if referral is required.

Incidence of Complications After Carotid Sinus Massage in Old er Patients with Syncope

OBJECTIVE: To review the incidence of neurological complications occurring after carotid sinus massage performed for diagnostic purposes.

Fludrocortisone in the treatment of hypotensive disorders in the elderly.

OBJECTIVE: To evaluate tolerance of fludrocortisone in older patients with hypotensive disorders. DESIGN: Prospective case series. SETTING: Syncope clinic. PATIENTS: 64 Consecutive patients over 65 years (mean age 80 years) with one or more hypotensive disorders (orthostatic hypotension, vasodepressor carotid sinus syncope, and/or vasodepressor neurocardiogenic syncope. INTERVENTIONS: Fludrocortisone in daily doses of 100 micrograms [corrected] (72%), 50 micrograms [corrected] (27%), and 200 micrograms [corrected] (one patient). MAIN OUTCOME MEASURES: Adverse events, treatment withdrawal. RESULTS: During follow up 13 patients died of unrelated causes. Of the remainder 33% discontinued fludrocortisone at a mean of five months. Reasons for discontinuing treatment were hypertension, five; cardiac failure, four; depression, three; oedema, three; and unspecified, two. In those who continued treatment supine systolic and diastolic blood pressure did not differ significantly from baseline (follow up two to 21 months). Hypokalaemia developed in 24% at a mean of eight months; in no case was treatment withdrawn because of hypokalaemia. CONCLUSION: Fludrocortisone, even in low doses, is poorly tolerated in the long term in older patients with hypotensive disorders.

The Newcastle protocols 2008: an update on head-up tilt table testing and the management of vasovagal syncope and related disorders

Since their publication in 2000, the Newcastle protocols1 on head-up tilt testing in the diagnosis of vasovagal syncope and related disorders have provided a succinct and practical guide for those setting up and managing syncope services incorporating the investigation and management of neurally mediated disorders. In the intervening seven years our protocols have changed in line with published evidence on new methodologies and management strategies and our own clinical experience (with more than 1000 new and 3000 review patients seen each year at our specialist syncope facility), so the time is ripe for a fresh approach. Much of this information is available in a number of important papers on syncope management2–4 and pacing indications5 6; while comprehensive, these guidelines are also lengthy and inclusive of competing methodologies. They are therefore less accessible for those needing a more prescriptive and pragmatic view. The Newcastle protocols 2008 presented below provide such a view. Since these protocols reflect current clinical practice, an exhaustive review of the evidence base for the various methodologies presented will not be attempted—the reader should consult the more detailed papers referenced if this is required.2–6 Similarly some prior knowledge of the subject matter is assumed, in particular the differentiation between syncope and non-syncopal loss of consciousness as well as the diagnostic process leading to head-up tilt table testing.2 3 The protocols are designed for adults with syncope (defined as transient loss of consciousness with loss of postural tone and spontaneous and complete recovery), with no upper limit on age. The Newcastle protocols 2008 are intended to complement rather than reproduce the originals, so only new information will be presented, occasionally with a summarised version of the old to aid clarity. Still-valid detailed prior information will be referenced to the …

Prevalence of family history in vasovagal syncope and haemodynamic response to head up tilt in first degree relatives

Abstract. Vasovagal syncope is an exaggerated form of the common faint affecting all age groups. Aetiology is unknown but the tendency for the disease to run in families has previously been noted. Aim: To determine the true prevalence of family history in subjects with a definitive diagnosis of vasovagal syncope made by positive head up tilt with symptom reproduction. To determine the strength of the genetic effect in vasovagal syncope by calculation of sibling (λs) and offspring (λo) relative risk. Haemodynamic responses to head up tilt were also examined in a sample of first-degree relatives of those with vasovagal syncope. Results: All subjects identified from the Cardiovascular Investigation Unit database with a definitive diagnosis of vasovagal syncope (n = 603) between 1993–2001 were asked to complete a questionnaire. 19 % had positive family history for blackouts or faints. From these pedigrees and using a crude estimate of population prevalence, sibling and offspring relative risk was calculated: λs = 1080, λo = 1356. Eleven first-degree relatives from 6 families attended for head up tilt testing with glyceryl trinitrate (GTN) provocation (4 unaffected, 7 affected). All subjects had symptoms in response to tilt in association with a range of haemodynamic responses. Conclusions: Vasovagal syncope has a strong genetic component. Elucidating underlying genetic mechanisms may lead to more effective, specific treatments.

A study comparing VVI and DDI pacing in elderly patients with carotid sinus syndrome.

OBJECTIVE: To determine whether single chamber ventricular demand (VVI) pacing is adequate for elderly patients with carotid sinus syndrome. DESIGN: Prospective double blind randomised cross over study. SETTING: Tertiary referral centre. PATIENTS: 30 consecutive patients aged over 60 years with carotid sinus syndrome referred for cardiac pacing. INTERVENTION: Patients underwent dual chamber pacemaker implantation and were then randomised to two three-month periods of VVI and DDI pacing. MAIN OUTCOME MEASURES: Responses to cardiovascular tests (vasodepression during carotid sinus massage, pacemaker effect, postural blood pressure measurements, and response to head up tilt), and symptoms. RESULTS: 11 patients developed profound hypotension during upright carotid sinus massage while pacing VVI compared with only two while pacing DDI. The upright pacemaker effect was greater in VVI (VVI, -31 (SD 19) mm Hg v DDI, -4 (12) mm Hg; P < 0.001). Postural blood pressure measurements and responses to head up tilt did not vary. Eleven patients were unable to tolerate VVI pacing and had to be withdrawn early from this limb of the study (group A). Fourteen of the remainder completed diary cards and did not express a preference (group B). No patient preferred VVI. Group A patients were older (group A, 78 (6) years v group B, 70 (9) years; P < 0.05), were more likely to be female (group A, 73% v group B, 14%; P < 0.01), and were more likely to have orthostatic hypotension while pacing DDI (group A, 46% v group B, 0%; P < 0.01). Group A and B patients could not be differentiated by other prepacing clinical or haemodynamic variables. CONCLUSIONS: Elderly patients with carotid sinus syndrome are likely to develop symptomatic hypotension following VVI pacing. The optimum pacing mode for individual patients cannot be predicted by simple cardiovascular tests before pacing.

Unprovoked and Glyceryl Trinitrate–Provoked Head‐Up Tilt Table Test Is Safe in Older People: A Review of 10 Years' Experience

Objectives: To test the safety of the head‐up tilt test (HUT) in older adults.

Dizziness in the older person

Dizziness is one of the commonest symptoms described by older people and is associated with balance disorders, functional decline and falls. 2006 Cambridge University Press.

A Novel Approach to Proactive Primary Care–Based Case Finding and Multidisciplinary Management of Falls, Syncope, and Dizziness in a One-Stop Service: Preliminary Results

National and international evidence and guidelines on falls prevention and management in community‐dwelling elderly adults recommend that falls services should be multifactorial and their interventions multicomponent. The way that individuals are identified as having had or being at risk of falls in order to take advantage of such services is far less clear. A novel multidisciplinary, multifactorial falls, syncope, and dizziness service model was designed with enhanced case ascertainment through proactive, primary care–based screening (of individual case notes of individuals aged ≥60) for individual fall risk factors. The service model identified 4,039 individuals, of whom 2,232 had significant gait and balance abnormalities according to senior physiotherapist assessment. Significant numbers of individuals with new diagnoses ranging from cognitive impairment to Parkinsons disease to urgent indications for a pacemaker were discovered. More than 600 individuals were found who were at high risk of osteoporosis according to World Health Association Fracture Risk Assessment Tool score, 179 with benign positional paroxysmal vertigo and 50 with atrial fibrillation. Through such screening and this approach, Comprehensive Geriatric Assessment Plus (Plus falls, syncope and dizziness expertise), unmet need was targeted on a scale far outside the numbers seen in clinical trials. Further work is needed to determine whether this approach translates into fewer falls and decreases in syncope and dizziness.