Roberto Maggi Centro Aritmologicoe Syncope Unit–Lavagna ... · PDF fileRoberto Maggi...
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Ilmassaggio delseno carotideoRobertoMaggi
CentroAritmologico eSyncope Unit – Lavagna,Italia
Tigullio Cardiologia,7aprile2016
Carotid sinus hypersensitivity Glossopharyngeal
nerveGlossopharyngeal nerve
Vagus nerveVagus nerve
Carotid sinus nerveCarotid sinus nerve
Carotid sinus Carotid sinus
Carotid sinus massage responses:
Ageing process?
Syndrome?
CSM is the tool for evaluation of CS reflex arc function
Age (years)
% CSS
Patients 205 161 240 415 462 236
Results and complications of CSM. Puggioni E et al. Am J Cardiol 2002
10 20 30 40 50 60 70 80Age at onset
ClassicalVVS
Situational Non-classicalVVS
Carotid sinus
Age of onset of Reflex SyncopeAge of onset of Reflex Syncope
Carotid sinus syndrome“Method of Symptoms”
• Carotid sinus hypersensitivity (CSH):asystole ≥3 sec and/or SBP fall ≥ 50 mmHg(irrespective of symptoms)
• Carotid sinus syndrome (CSS):reproduction of syncope in presence of CSH
• Carotid sinus hypersensitivity (CSH):asystole ≥3 sec and/or SBP fall ≥ 50 mmHg(irrespective of symptoms)
• Carotid sinus syndrome (CSS):reproduction of syncope in presence of CSH
Definitions
Brignole M et al. Eur Heart J 2004 25, 2054–2072Moya A. et al. Eur Heart J. 2009;30:2631–2671
Low specificity of CSH !!!
272 participants sampled from a single general practice register who underwent supine and upright CSM
Pacing in elderly recurrent fallers with carotid sinushypersensitivity: a RCT crossover trial
Parry S, et al. Heart 2009
Asyndrome isasetofmedicalsigns andsymptoms thatarecorrelatedwitheachotherandoftenwithaspecificdisease
SyncopeUnitProject2(SUP2)
• Certain or suspected reflex syncopes
• Short (<10”) or no prodromes
• Recurrent
• Severe, i.e., unpredictable
• Onset in older age
EurHeartJ 2015;36:1529–35
Number of patients n=66
Age 77±9
Men 68%
Syncope events:
- Total syncopes, median 4 (3-6)
- Syncopes in the previous 2 years, median 3 (2-4)
- Age on first syncope 70±16
- Syncopes without or with prodromes <10 s, 88%
- Hospitalization for syncope 55%
- Injuries related to fainting
- Major injuries 11%
- Minor injuries 69%
Medical history
- Structural cardiac abnormalities 23%
- ECG abnormalities 25%
- Hypertension 58%
- Diabetes 19%
- Neurological/psychiatric disorders 16%
Concomitant vasoactive medications 59%
Typical features of CSS
Clinical features of CSS
SyncopeUnitProject2(SUP2) CSS(n=66patients)
EuropeanHeartJournal 2015;36:1529–35
95%
5% Vasovagal prodromes
Noprodromes
Carotid sinus massage: “Method of Symptoms”
Positive responseCSS is established if spontaneous symptoms (syncope or presyncope) are reproduced in presence of hypotension ± asystolic pause
Positive responseCSS is established if spontaneous symptoms (syncope or presyncope) are reproduced in presence of hypotension ± asystolic pause
No cut-off value of SBP fall or asystolic pause is required
Solari D et al. Circ Arrhythm Electrophysiol 2014; 7: 505-510
Study PM groupn/N
No PM groupn/N
Sugrue1986
2/23 7/33
Brignole1992 (a)
3/32 16/28
Claesson2007
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)
Testforheterogeneity:p=0.39
Cardiac pacing in CSS by Method of Symptoms
Europace 2011; 13: 462–464
CSH+ ILR+
18Asystole Asystole89%
11% Noasystole
16
2
Total18pts
ISSUE 2
SYNCOPE
Cardioinhibitory carotidsinushypersensitivitypredictsanasystolicmechanismofspontaneous neurally-mediatedsyncope
Maggiet al.Europace2007;9,563–567
Conclusions
1.CSH is an ageing process
2.CSS is an ageing-related syndrome
3.The underlying disease is poorly understood
Carotid sinus massageresponses
CSM is the tool for evaluation of CS reflex arc function
Carotid Sinus Massage (CSM)Carotid Sinus Massage (CSM)
• CSM is raccomanded in patients over age 40years with uncertain syncope
• A positive response is diagnostic if no competing diagnosis
• In case of risk of stroke, avoid massage
• CSM is raccomanded in patients over age 40years with uncertain syncope
• A positive response is diagnostic if no competing diagnosis
• In case of risk of stroke, avoid massage
Carotid sinus massage:“Method of Symptoms”
Complications of CSMComplications of CSM
Method ofsymptoms:3TIA(0.17%)Puggioni et al.AmJCardiol.2002Mar1;89(5):599-601
ShortMethod:0.28%- 0.45%complications(Munro1994&Davies 1998)
Carotid sinus massage: “Method of Symptoms”Carotid sinus massage: “Method of Symptoms”
Method
• Ecg monitoring and continuous BPmeasurement during carotid massage
• Duration of massage of 10 seconds (interrupted in case of syncope)
• Massage both supine and erect, on the right and left sinuses separately
• (in case of asystole) massage repeated after atropine 0.02 mg/Kg i.v.
Method
• Ecg monitoring and continuous BPmeasurement during carotid massage
• Duration of massage of 10 seconds (interrupted in case of syncope)
• Massage both supine and erect, on the right and left sinuses separately
• (in case of asystole) massage repeated after atropine 0.02 mg/Kg i.v.
ESC Task Force on Management (Diagnosis and Treatment) of Syncope
“Method of Symptoms”: CI form
100
0
BPON OFF10 s
Syncope
BaselineBaseline
Atropine 0.02 mg/Kg i.v.Atropine 0.02 mg/Kg i.v.
100
0
BPON OFF10 s
No symptoms
“Method of Symptoms”: MIXED form
150
0
BPON OFF10 s
S
ON OFF11 s150
0
BP
Syncope
Syncope
Atropine 0.02 mg/Kg i.v.Atropine 0.02 mg/Kg i.v.
BaselineBaseline
Carotid sinus syndromeClassification of the positive responses
Cardioinhibitory form: • CSM after atropine: no more symptoms
Mixed form:• CSM after atropine: milder symptoms due to SBP fall ≥50 mmHg
Vasodepressor form:
• Baseline CSM: fall of SBP >50 mmHg with reproduction ofspontaneous symptoms (no asystole >3 sec)
CSM, EBC & HUT in 100 patients with syncope Brignole M et al. Am Heart J 1991; 122: 1644
Positive 79 ptsNegative 21 pts
24
CSM49%
HUT43%
EBC16%
19 20
24
8
2
Positive responses
Mean age 60±18
Actuarial estimates:
• 7% at 1 year
• 16% at 3 years
• 20% at 5 years
CSS: recurrence of syncope with cardiac pacing
PuggioniEetal.AmJCardiol 2002;89:599
Pm, TT negative
Pm, TT Positive
No Pm, ILRLog rank for trend:p = 0.01
p = 0.03
SyncopeUnitProject2(SUP2) SUP 2 study: 3-years extended follow-up
Europace 2015
Critical issues for pacing in CSS
• Mixed forms of CSS, i.e., important VD reflex
• Associated positivity of tilt testing, i.e., hypotensive susceptibility
Cardiac pacing is effective in CSS, butsyncope is more likely to recur in presence of:
CSS: the underlying disease (I)
Age-related degenerative CNS disease ? (impairment of compensatory baroreflexes
and cardiac SN effectors?)
CSM is the tool for evaluation of CS reflex arc function
CSS is frequently associated with otherabnormal reflexes, but not with typical VVS
APL, μM
Adenosine phenotypes and neurally-mediated syncope
n=57 n=9 n=23 n=30 n=40
GuieuRetal.Adenosine andclinical forms.JACC2015;66:202-3
1. CSS, a form of “Low Adenosine” disease ?
2. “Low Adenosine” disease is different from
Vasovagal syncope
CSS: the underlying disease (II)
CSM is the tool for evaluation of CS reflex arc function
ConclusionsConclusions
• CSH is not a precursor of CSS• CSS is a frequent cause of syncope
• CSM should be performed systematicallyin the patients after the initial evaluation
• CSM must be performed in upright position (49% false negative rate if only supine)
• The “Method of Symptoms” is safe, with a low complications rate
10 20 30 40 50 60 70 80
1,2
1,0
0,8
0,6
0,4
0,2
0,0
Age
APL
20 30 40 50 60 70 80 90
2,0
1,5
1,0
0,5
0,0
Age
APL
20 30 40 50 60 70 80
0,8
0,7
0,6
0,5
0,4
0,3
Age
APL
P=0.54
Control group No prodromes and CSS groups
P=0.49
P=0.92
Situational group
10 20 30 40 50 60 70 80
3,5
3,0
2,5
2,0
1,5
1,0
0,5
0,0
Age
APL
VVS group
P=0.70
712
63
0
17
74
50
26
4250
19
38
11
58
33
0
10
20
30
40
50
60
70
80
Noprodr n=27
CSSn=8
Sitn=19
VVSn=12
Cntrn=40
TT
TC
CC
%
GenotypeoftheA2A Rgeneplomorphism
Adenosine phenotypes and neurally-mediated syncope
GuieuRetal.Adenosine andclinical forms.JACC2015;66:202-3
Summary
Ageing process? Syndrome ?
1. CSH is an ageing process
2. CSS is an age-related
syndrome
Which is the underlyingdisease ?
3. Age-related degenerative
CNS disease ?
4. A form of “Low Adenosine”
disease ?
5. “Low Adenosine” disease is
different from VasoVagal
syncope
Dowereallyunderstandcarotidsinusmassageresponses?
CSM, EBC & HUT in 100 patients with syncope Brignole M et al. Am Heart J 1991; 122: 1644
Positive CSM 49 ptsSituational 39 pts
26
Situational CSM +
13 36
No prodromes Low AplLow A2AR
TC variant
Controls
NormalAPl
SituationalHigh APLCC variant
VVS
High A2AR
NormalA2AR
TT variant
CSS
GuieuRetal.Adenosine andclinical forms.JACC2015;66:202-3
No prodromes & CSS
Low AplLow A2AR
TC variant
Controls
NormalAPl
SituationalHigh APLCC variant
VVS
High A2AR
NormalA2AR
TT variant
GuieuRetal.Adenosine andclinical forms.JACC2015;66:202-3
• CSHis very frequent inolder people
• 39%CSHinan unselected cohort
• 35%CSHinolder peoplewith nohystory of syncope orfalls
• Syncope occurred only inaminority of patients with CSH
Occ Arch Int Med.2006;166:515-20
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)
PM ILR p
Falls 3.4 ± 6.6 1.4 ± 2.1 .07
Syncope 0.32 ± 0.82 0.35 ± 1.08 .25
…current criteria for CSH are too sensitive, and this may well be the underlying reason for the reported high prevalence of CSH in the general older population
NewcriteriasuggestedforCSH
• Spontaneousclinicalsymptomsand
• Asystole of≥6sand/or
• Afallinmeanarterialpressurebelow60mmHglastingfor≥6s
PPVCI form
(n=86 pts)Mixed form (n= 46 pts)
Max asystolic pause, s
Max asystolic pause, s
99% 3.2 4.095% 4.6 4.490% 5.0 4.975% 6.0 5.750% 7.9 7.5
25% 9.1 8.610% 10.0 10.05% 11.0 12.01% 13.2 12.0
CSS by Method of Symptoms
Solari D et al. Circ Arrhythm Electrophysiol 2014; 7: 505-510
SSS & NMSBrignole et al. Am J Cardiol 1991; 68: 1032-6
20%
20%
34%
26%CSM +
HUT +CSM/HUT +
Negative
35 pts with SSS and syncope
CSSTherapy:pacemakerimplantation
Classe Raccomandazioni per il trattamento delle sincopi
neuromediate
Evidenza
IElettrostimolazione cardiaca nei pazienti con sindrome seno carotidea a prevalente componente cardioinibitrice
B
Brignole,2011
RRR of syncope recurrence after PM in controlledstudies in which CCS was diagnosed by means of the
“Method of Symptoms”
Carotidsinusmassage
WhyperformCSM?
• A positive response to CSM is frequent (from 4% inpatients >40 yrs to 41% in pts >80 yrs)
• CSS is common in older patients with unexplainedfalls
• Major trauma are more frequent in CSS than to theother pts with syncope evaluated in ED
• CSS can be treated in order to reduce syncopeburden
Carotid sinus massage: “Method of Symptoms”Carotid sinus massage: “Method of Symptoms”
CSM sequence:• Supine right massage ≥10 sec• Supine left massage ≥10 sec• Orthostatic blood pressure drop • Standing right massage ≥10 sec• Standing left massage ≥10 sec• (in case of asystole) massage repeated
after atropine 0.02 mg/Kg i.v.
CSM sequence:• Supine right massage ≥10 sec• Supine left massage ≥10 sec• Orthostatic blood pressure drop • Standing right massage ≥10 sec• Standing left massage ≥10 sec• (in case of asystole) massage repeated
after atropine 0.02 mg/Kg i.v.
ESC Task Force on Management (Diagnosis and Treatment) of Syncope
Carotid sinus massage: “Method of Symptoms”Carotid sinus massage: “Method of Symptoms”
• Neck rotated contralaterally• Anterior margin of the sternocleomastoid
muscle at the level of the cricoid cartilage• 3 fingers over the zone of maximum
carotid artery pulse• Firm massage for 10 sec or till syncope
occurs
ConclusionsConclusions
• CSS is a frequent cause of syncope in the elderly.
• CSM should be performed systematically in the patients after the initial evaluation
• CSM must be performed in upright position (49% false negative rate if only supine)
• The “Method of Symptoms” is safe, with a low complications rate
ISSUE 2International Study on Syncope of Uncertain Etiology 2
ISSUE 2
SYNCOPE
Conclusions• A long asystole, mainly due to sinus arrest, is the mostfrequent finding at the time of spontaneous syncope inpatients with cardioinhibitory CSH and is consistent withthe aetiology of neurally-mediated syncope.
• A cardioinhibitory response during CSM predicts, with aprobability of 89%, that a long asystolic reflex is alsopresent at the time of spontaneous syncope.
• The finding of asystolic syncope during spontaneousepisodes forms the background for the potential benefitof cardiac pacing in CSH patients (98% reduction of thesyncope burden in this study)
Carotid sinus syndromeCarotid sinus syndrome
ESC Task Force on Management (Diagnosis and Treatment) of Syncope
Spontaneous carotid sinus syndrome: close relationship with accidental mechanical manipulation of the carotid sinuses, reproduced by carotid sinus massage. Rare, about 1% of all causes of syncope
Induced carotid sinus syndrome: abnormal response to carotid sinus massage and an otherwise negative work-up. Much more frequent, 26% to 60% of patients affected by unexplained syncope
Spontaneous carotid sinus syndrome: close relationship with accidental mechanical manipulation of the carotid sinuses, reproduced by carotid sinus massage. Rare, about 1% of all causes of syncope
Induced carotid sinus syndrome: abnormal response to carotid sinus massage and an otherwise negative work-up. Much more frequent, 26% to 60% of patients affected by unexplained syncope
CSM:MethodofSymptoms”
Theprocedureisconsideredpositiveifsymptomsarereproduced inpresenceofasystole≥3 secand/orafallinSBP≥50mmHg
Apositiveresponse(symptomreproduction)isdiagnosticofthecauseofsyncopeintheabsenceofanyothercompetingdiagnosis
ESCTaskForceonManagement(DiagnosisandTreatment)ofSyncope,2009
WhenCSMispositive?
WhenCSMisdiagnostic?
Carotid sinus massage: “Method of Symptoms”Carotid sinus massage: “Method of Symptoms”
Positive response• The procedure is considered positive if
symptoms are reproduced in presence of asystole ≥3 sec and/or a fall in SBP ≥50 mmHg.
• A positive response is diagnostic of the cause of syncope in the absence of any other competing diagnosis
Positive response• The procedure is considered positive if
symptoms are reproduced in presence of asystole ≥3 sec and/or a fall in SBP ≥50 mmHg.
• A positive response is diagnostic of the cause of syncope in the absence of any other competing diagnosis
ESC Task Force on Management (Diagnosis and Treatment) of Syncope