Il PM nella sindrome senocarotidea: tutto chiaro? Michele Brignole

Centro aritmologico e Syncope Unit – Lavagna

Carotid sinus

hypersensitivity Glossopharyngeal nerve Vagus

nerve

Carotid sinus nerve

Carotid sinus

Carotid Sinus Massage

CSM is the tool for evaluation of CS reflex arc function

CSS: syncope recurrence rate

%

Years

Blanc 84

Brignole 92

Brignole 92

Claesson 07

Claesson 07

Menozzi 93

Sugrue 86

Walter 78

Claesson 07

Claesson 07 Brignole 92

Brignole 92 Morley 82

Blanc 84 Stryjer 86

Sugrue 86

Crilley 97

Lopes 11

Pacemaker

No therapy

Europace 2011; 13: 462–464

Brignole et al. Am J Cardiol 1992; 69: 1039-1043

Cardiac pacing in CSS by Method of Symptoms

Study PM group

n/N

No PM group

n/N

Sugrue

1986

2/23 7/33

Brignole

1992 (a)

3/32 16/28

Claesson

2007

3/30 12/30

Total 8/85 35/91

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

Relative risk

95% CI

PM better No PM better

Relative risk

95% CI

0.41 (0.10-1.56)

0.16 (0.06-0.40)

0.33 (0.10-0.97)

0.24 (0.12-0.48)

Test for heterogeneity: p=0.39

Cardiac pacing in CSS by Method of Symptoms

Europace 2011; 13: 462–464

Actuarial estimates:

• 7% at 1 year

• 16% at 3 years

• 20% at 5 years

CSS: recurrence of syncope with cardiac pacing

Puggioni E et al. Am J Cardiol 2002; 89: 599

Critical issues in CSS

How to assess the magnitude of the

vasodepressor reflex (hypotensive

susceptibility) which is virtually present

in every CSS patient ?

Critical issues for pacing in CSS

• Lack of reproduction of symptoms during CSM, i.e., low specificity

• Mixed forms of CSS, i.e., important VD reflex

• Associated positivity of tilt testing, i.e., hypotensive susceptibility

Syncope is more likely to recur in presence of:

Carotid sinus syndrome: definitions

• Carotid sinus hypersensitivity (CSH):

asystole 3 sec and/or SBP fall 50 mmHg

(irrespective of symptoms)

Brignole M et al. Eur Heart J 2004 25, 2054–2072

Moya A. et al. Eur Heart J. 2009;30:2631–2671

A positive response induced by CSM does not

necessarily equate with clinical relevance

False positive responses of CSH !!!

272 participants sampled from a single general practice register who

underwent supine and upright CSM

(6.6%) (5%) = CSS

Pacing in elderly recurrent fallers with carotid sinus

hypersensitivity: a RCT crossover trial

Parry S, et al. Heart 2009

Heart 2010; 96: 347-351

Inclusion criteria

• Unexplained falls that is: 1) no clear history of a trip; and 2) denial of loss

of consciousness

• CSH (3 sec asystole)

Carotid sinus hypersensitivity (CSH)

Critical issues for pacing in CSS

• Lack of reproduction of symptoms during CSM, i.e., low specificity

• Mixed forms of CSS, i.e., important VD reflex

• Associated positivity of tilt testing, i.e., hypotensive susceptibility

Syncope is more likely to recur in presence of:

Results: CI vs Mixed (atropine test)

Solari D et al. Circ Arrhythm Electrophysiol 2014

Brignole et al. Am J Cardiol 1992; 69: 1039-1043

Cardiac pacing in CSS by Method of Symptoms

Europace (2011) 13, 572–575

Recurrence CI: 13% Recurrence Mixed: 38%

Critical issues for pacing in CSS

• Lack of reproduction of symptoms during CSM, i.e., low specificity

• Mixed forms of CSS, i.e., important VD reflex

• Associated positivity of tilt testing, i.e., hypotensive susceptibility

Syncope is more likely to recur in presence of:

Am J Cardiol 1995; 76: 720

Non-CI forms

CI form

Negative or not performed

Recurrence of syncope according to tilt test results

Log rank: p=0.008

Solari d et al. Europace 2014; 16: 928-934

Perspectives

• Quantification of VD component is clinically

relevant, since PM therapy is less effective when

the VD effect is large (vs CI)

• Mixed form is an independent predictor of

symptom recurrence with PM therapy

• Dominant VD forms benefit from withdrawal of

hypotensive drug therapy