Il massaggio del seno carotideo Roberto Maggi Centro Aritmologico e Syncope Unit Lavagna, Italia

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1 Il massaggio del seno carotideo Roberto Maggi Centro Aritmologico e Syncope Unit Lavagna, Italia Tigullio Cardiologia, 7 aprile 2016

2 Carotid sinus hypersensitivity Vagus nerve Glossopharyngeal nerve Carotid sinus nerve Carotid sinus

3 CS reflex arc

4 CSM is the tool for evaluation of CS reflex arc function Carotid sinus massage responses: Ageing process? Syndrome?

5 % CSS Age (years) Patients Results and complications of CSM. Puggioni E et al. Am J Cardiol 2002

6 Age of onset of Reflex Syncope Classical VVS Situational Non-classical VVS Carotid sinus Age at onset

7 Carotid sinus syndrome Method of Symptoms Definitions 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 Brignole M et al. Eur Heart J , Moya A. et al. Eur Heart J. 2009;30:

8 Low specificity of CSH!!! 272 participants sampled from a single general practice register who underwent supine and upright CSM

9 Pacing in elderly recurrent fallers with carotid sinus hypersensitivity: a RCT crossover trial Parry S, et al. Heart 2009

10 A syndrome is a set of medical signs and symptoms that are correlated with each other and often with a specific disease

11 CSS: definition Reproduction of syncope by means of CSM + Clinical features compatible with CSS

12 Syncope Unit Project 2 (SUP 2) Clinical features of CSS Typical features of CSS Certain or suspected reflex syncopes Short (<10 ) or no prodromes Recurrent Severe, i.e., unpredictable Onset in older age Eur Heart J 2015; 36: 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%

13 Syncope Unit Project 2 (SUP 2) CSS (n=66 patients) 5% Vasovagal prodromes No prodromes 95% European Heart Journal 2015; 36:

14 Carotid sinus massage: Method of Symptoms Positive response CSS 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:

15 Cardiac pacing in CSS by Method of Symptoms Brignole et al. Am J Cardiol 1992; 69:

16 Cardiac pacing in CSS by Method of Symptoms Study PM group n/n No PM group n/n Relative risk 95% CI Relative risk 95% CI Sugrue 1986 Brignole 1992 (a) Claesson /23 7/33 3/32 16/28 3/30 12/ ( ) 0.16 ( ) 0.33 ( ) Total 8/85 35/ ( ) Test for heterogeneity: p= PM better No PM better Europace 2011; 13:

17 SYNCOPE ISSUE 2 Cardioinhibitory carotid sinus hypersensitivity predicts an asystolic mechanism of spontaneous neurally-mediated syncope Maggi et al. Europace 2007; 9, CSH + Total 18 pts ILR + Asystole % Asystole 2 11% No asystole

18 CSM is the tool for evaluation of CS reflex arc function Carotid sinus massage responses Conclusions 1.CSH is an ageing process 2.CSS is an ageing-related syndrome 3.The underlying disease is poorly understood

19 Carotid Sinus Massage (CSM) CSM is raccomanded in patients over age 40 years with uncertain syncope A positive response is diagnostic if no competing diagnosis In case of risk of stroke, avoid massage

20 Carotid sinus massage: Method of Symptoms Complications of CSM Method of symptoms: 3 TIA (0.17%) Puggioni et al. Am J Cardiol Mar 1;89(5): Short Method: 0.28% % complications (Munro 1994 & Davies 1998)

21 Carotid sinus massage: Method of Symptoms Method Ecg monitoring and continuous BP measurement 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

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25 0 Method of Symptoms : CI form Baseline ON 10 s OFF Syncope BP 100 Atropine 0.02 mg/kg i.v. 0 ON 10 s OFF No symptoms BP 100

26 0 Method of Symptoms : MIXED form Baseline ON 10 s OFF Syncope BP 150 Atropine 0.02 mg/kg i.v. 0 ON 11 s OFF Syncope S BP 150

27 Carotid sinus syndrome Classification 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 of spontaneous symptoms (no asystole >3 sec)

28 Europace (2011) 13, Recurrence CI: 13% Recurrence Mixed: 38%

29 CSM, EBC & HUT in 100 patients with syncope Brignole M et al. Am Heart J 1991; 122: 1644 Positive responses CSM 49% HUT 43% Positive 79 pts Negative 21 pts Mean age 60±18 EBC 16%

30 CSS: recurrence of syncope with cardiac pacing Actuarial estimates: 7% at 1 year 16% at 3 years 20% at 5 years Puggioni E et al. Am J Cardiol 2002; 89: 599

31 Am J Cardiol 1995; 76: 720

32 Syncope Unit Project 2 (SUP 2) SUP 2 study: 3-years extended follow-up Pm, TT negative p = 0.03 Pm, TT Positive Log rank for trend: p = 0.01 No Pm, ILR Europace 2015

33 Critical issues for pacing in CSS Cardiac pacing is effective in CSS, but syncope is more likely to recur in presence of: Mixed forms of CSS, i.e., important VD reflex Associated positivity of tilt testing, i.e., hypotensive susceptibility

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35 CSM is the tool for evaluation of CS reflex arc function CSS: the underlying disease (I) Age-related degenerative CNS disease? (impairment of compensatory baroreflexes and cardiac SN effectors?) CSS is frequently associated with other abnormal reflexes, but not with typical VVS

36 Adenosine phenotypes and neurally-mediated syncope APL, μm n=57 n=9 n=23 n=30 n=40 Guieu R et al. Adenosine and clinical forms. JACC 2015; 66: 202-3

37 CSM is the tool for evaluation of CS reflex arc function CSS: the underlying disease (II) 1. CSS, a form of Low Adenosine disease? 2. Low Adenosine disease is different from Vasovagal syncope

38 Conclusions CSH is not a precursor of CSS CSS is a frequent cause of syncope 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

39 Control group No prodromes and CSS groups 0,8 P=0.54 2,0 P=0.49 0,7 1,5 0,6 APL APL 1,0 0,5 0,4 0,5 0, Age 0, Age 1,2 Situational group P=0.92 3,5 VVS group P=0.70 1,0 3,0 0,8 2,5 2,0 APL 0,6 APL 1,5 0,4 1,0 0,2 0,5 0, Age 0, Age

40 Adenosine phenotypes and neurally-mediated syncope Genotype of the A 2A R gene plomorphism % No prodr n= CSS n= Sit n= VVS n= Cntr n=40 33 TT TC CC Guieu R et al. Adenosine and clinical forms. JACC 2015; 66: 202-3

41 Do we really understand carotid sinus massage responses? Summary Ageing process? Syndrome? Which is the underlying disease? 1. CSH is an ageing process 2. CSS is an age-related syndrome 3. Age-related degenerative CNS disease? 4. A form of Low Adenosine disease? 5. Low Adenosine disease is different from VasoVagal syncope

42 CSM, EBC & HUT in 100 patients with syncope Brignole M et al. Am Heart J 1991; 122: 1644 Situational CSM Positive CSM 49 pts Situational 39 pts

43 CSS Low Apl Low A 2A R No prodromes TC variant VVS Normal APl Controls Normal A 2A R High APL CC variant High A 2A R Situational TT variant Guieu R et al. Adenosine and clinical forms. JACC 2015; 66: 202-3

44 No prodromes & CSS Low Apl Low A 2A R TC variant Controls VVS Normal APl Normal A 2A R High APL CC variant High A 2A R Situational TT variant Guieu R et al. Adenosine and clinical forms. JACC 2015; 66: 202-3

45 CSH is very frequent in older people 39% CSH in an unselected cohort 35% CSH in older people with no hystory of syncope or falls Syncope occurred only in a minority of patients with CSH Occ Arch Int Med. 2006;166:515-20

46 Heart 2010; 96: 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 ± ± Syncope 0.32 ± ±

47 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

48 New criteria suggested for CSH Spontaneous clinical symptoms and Asystole of 6 s and/or A fall in mean arterial pressure below 60 mmhg lasting for 6 s

49 CSS by Method of Symptoms PPV CI form (n=86 pts) Mixed form (n= 46 pts) Max asystolic pause, s Max asystolic pause, s 99% % % % % % % % % Solari D et al. Circ Arrhythm Electrophysiol 2014; 7:

50 SSS & NMS Brignole et al. Am J Cardiol 1991; 68: pts with SSS and syncope 20% Negative 26% CSM + 34% CSM/HUT + 20% HUT +

51 CSS Therapy: pacemaker implantation Classe I Raccomandazioni per il trattamento delle sincopi neuromediate Elettrostimolazione cardiaca nei pazienti con sindrome seno carotidea a prevalente componente cardioinibitrice Evidenza B

52 CSS Therapy: is PM really effective? Brignole, 2011

53 RRR of syncope recurrence after PM in controlled studies in which CCS was diagnosed by means of the Method of Symptoms Brignole, 2011

54 Carotid sinus massage Why perform CSM? A positive response to CSM is frequent (from 4% in patients >40 yrs to 41% in pts >80 yrs) CSS is common in older patients with unexplained falls Major trauma are more frequent in CSS than to the other pts with syncope evaluated in ED CSS can be treated in order to reduce syncope burden

55 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. ESC Task Force on Management (Diagnosis and Treatment) of Syncope

56 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

57 Conclusions 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

58 ISSUE 2 ISSUE 2 International Study on Syncope of Uncertain Etiology 2 SYNCOPE Conclusions A long asystole, mainly due to sinus arrest, is the most frequent finding at the time of spontaneous syncope in patients with cardioinhibitory CSH and is consistent with the aetiology of neurally-mediated syncope. A cardioinhibitory response during CSM predicts, with a probability of 89%, that a long asystolic reflex is also present at the time of spontaneous syncope. The finding of asystolic syncope during spontaneous episodes forms the background for the potential benefit of cardiac pacing in CSH patients (98% reduction of the syncope burden in this study)

59 Carotid sinus syndrome 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 ESC Task Force on Management (Diagnosis and Treatment) of Syncope

60 CSM: Method of Symptoms When CSM is positive? The procedure is considered positive if symptoms are reproduced in presence of asystole 3 sec and/or a fall in SBP 50 mmhg When CSM is diagnostic? A positive response (symptom reproduction) 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, 2009

61 Positive response Carotid sinus massage: Method of Symptoms 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

62 How frequent is carotid sinus massage? min 25th 50th 75th max EGSYS hospitals 0,00% 0% 3% 10,00% 12% 20,00% 23% 30,00% 40,00% 50,00% 58% 60,00% 70,00% Percent patients