Carotid sinus hypersensitivity
- Brian Olshansky, MD
Brian Olshansky, MD
- Section Editor — Cardiac Arrhythmias
- Adjunct Professor of Medicine
- Des Moines University
Hypersensitivity of the afferent or efferent limbs of the carotid sinus reflex arc results in vagal activation and/or sympathetic inhibition, which leads to bradycardia and/or vasodilation; this is also called the carotid sinus syndrome or carotid sinus syncope.
Carotid sinus syncope is similar to vasovagal (neurocardiogenic) syncope since both are forms of reflex syncope reflecting alterations in autonomic tone with similar clinical manifestations. However, precipitating factors for these two types of syncope differ and carotid sinus hypersensitivity tends to occur in older patients. (See 'Prevalence and clinical features' below.)
Carotid sinus hypersensitivity will be reviewed here. Other types of reflex syncope including vasovagal syncope and general discussions of the pathogenesis, etiology, and evaluation of syncope are discussed separately. (See "Reflex syncope in adults: Clinical presentation and diagnostic evaluation" and "Syncope in adults: Epidemiology, pathogenesis, and etiologies" and "Syncope in adults: Clinical manifestations and diagnostic evaluation" and "Overview of craniofacial pain", section on 'Glossopharyngeal neuralgia'.)
PREVALENCE AND CLINICAL FEATURES
The frequency of carotid sinus hypersensitivity in patients with syncope depends upon how it is defined :
●"Spontaneous carotid sinus syndrome" is diagnosed when by history spontaneous syncope occurs after accidental mechanical manipulation (eg, pressure from shaving or tight collars) of the carotid sinuses. Syncope can often be reproduced by carotid sinus massage. This clinical syndrome is rare, accounting for about 1 percent of syncope cases .
- Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631.
- Thomas JE. Hyperactive carotid sinus reflex and carotid sinus syncope. Mayo Clin Proc 1969; 44:127.
- Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol 2001; 37:1921.
- Volkmann H, Schnerch B, Kühnert H. Diagnostic value of carotid sinus hypersensitivity. Pacing Clin Electrophysiol 1990; 13:2065.
- McIntosh SJ, Lawson J, Kenny RA. Clinical characteristics of vasodepressor, cardioinhibitory, and mixed carotid sinus syndrome in the elderly. Am J Med 1993; 95:203.
- Brignole M, Menozzi C, Gianfranchi L, et al. Carotid sinus massage, eyeball compression, and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J 1991; 122:1644.
- Sullivan RM, Olshansky B. Carotid sinus hypersensitivity: disease state or clinical sign of ageing? The need for hard endpoints. Europace 2010; 12:1516.
- Tan MP, Kenny RA, Chadwick TJ, et al. Carotid sinus hypersensitivity: disease state or clinical sign of ageing? Insights from a controlled study of autonomic function in symptomatic and asymptomatic subjects. Europace 2010; 12:1630.
- Krediet CT, Parry SW, Jardine DL, et al. The history of diagnosing carotid sinus hypersensitivity: why are the current criteria too sensitive? Europace 2011; 13:14.
- Humm AM, Mathias CJ. Unexplained syncope--is screening for carotid sinus hypersensitivity indicated in all patients aged >40 years? J Neurol Neurosurg Psychiatry 2006; 77:1267.
- Menozzi C, Brignole M, Lolli G, et al. Follow-up of asystolic episodes in patients with cardioinhibitory, neurally mediated syncope and VVI pacemaker. Am J Cardiol 1993; 72:1152.
- Maggi R, Menozzi C, Brignole M, et al. Cardioinhibitory carotid sinus hypersensitivity predicts an asystolic mechanism of spontaneous neurally mediated syncope. Europace 2007; 9:563.
- Morillo CA, Camacho ME, Wood MA, et al. Diagnostic utility of mechanical, pharmacological and orthostatic stimulation of the carotid sinus in patients with unexplained syncope. J Am Coll Cardiol 1999; 34:1587.
- Parry SW, Richardson DA, O'Shea D, et al. Diagnosis of carotid sinus hypersensitivity in older adults: carotid sinus massage in the upright position is essential. Heart 2000; 83:22.
- Kerr SR, Pearce MS, Brayne C, et al. Carotid sinus hypersensitivity in asymptomatic older persons: implications for diagnosis of syncope and falls. Arch Intern Med 2006; 166:515.
- Epstein AE, Baessler CA, Curtis AB, et al. Addendum to "Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations: a medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology": public safety issues in patients with implantable defibrillators: a scientific statement from the American Heart Association and the Heart Rhythm Society. Circulation 2007; 115:1170.
- Epstein AE, Miles WM, Benditt DG, et al. Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations. A medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology. Circulation 1996; 94:1147.
- Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350.
- Gillis AM, Russo AM, Ellenbogen KA, et al. HRS/ACCF expert consensus statement on pacemaker device and mode selection. Developed in partnership between the Heart Rhythm Society (HRS) and the American College of Cardiology Foundation (ACCF) and in collaboration with the Society of Thoracic Surgeons. Heart Rhythm 2012; 9:1344.
- Brignole M, Menozzi C, Lolli G, et al. Long-term outcome of paced and nonpaced patients with severe carotid sinus syndrome. Am J Cardiol 1992; 69:1039.
- Claesson JE, Kristensson BE, Edvardsson N, Währborg P. Less syncope and milder symptoms in patients treated with pacing for induced cardioinhibitory carotid sinus syndrome: a randomized study. Europace 2007; 9:932.
- Kenny RA, Richardson DA, Steen N, et al. Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE). J Am Coll Cardiol 2001; 38:1491.
- Grubb BP, Samoil D, Kosinski D, et al. The use of serotonin reuptake inhibitors for the treatment of recurrent syncope due to carotid sinus hypersensitivity unresponsive to dual chamber cardiac pacing. Pacing Clin Electrophysiol 1994; 17:1434.
- Dan D, Grubb BP, Mouhaffel AH, Kosinski DJ. Use of serotonin re-uptake inhibitors as primary therapy for carotid sinus hypersensitivity. Pacing Clin Electrophysiol 1997; 20:1633.