Σε όλους τους ασθενείς με σύνδρομο ευερέθιστου καρωτιδικού κόλπου και συγκοπή πρέπει να εμφυτεύεται μόνιμος βηματοδότης Κατά

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1 Σε όλους τους ασθενείς με σύνδρομο ευερέθιστου καρωτιδικού κόλπου και συγκοπή πρέπει να εμφυτεύεται μόνιμος βηματοδότης Κατά Δρ. H.Θ. Ζάρβαλης Καρδιολογική Κλινική Γ.Ν. Παπαγεωργίου Θεσσαλονίκη

2 Classification of CSS dominant cardioinhibitory form: 45% mixed form: 40% dominant vasodepressor form: 15% it has been shown that pacemaker therapy is less effective when the vasodepressor effect is large, compared to predominant cardioinhibition The role of pacemaker in hypersensitive carotid sinus syndrome. Ricardo Lopes Europace (2011)

3 At the heart of the arterial baroreflex: a physiological basis for a new classification of carotid sinus hypersensitivity The concept of asystole for >3 s without a fall in arterial pressure was based on blood pressure measured during CSM using a manually inflated arm cuff current criteria for CSH are too sensitive underlying reason for the reported high prevalence of CSH in the general older population CSS was found in 26% of 1719 consecutive patients performing appropriately CSM for syncope of uncertain origin cerebral anoxia reserve time of 5 8 s the average pause required to elicit symptoms is 7.9 s asystolic pause is at least 6 s long in 75% of patients with predominant cardioinhibitory CSH Journal of Internal Medicine. MAR 2013

4 The natural history of carotid sinus syncope and the effect of cardiac pacing studies are largely heterogeneous: Observational, RCT selection of patients: syncope, falls Time of CS massage CSM was performed on all patients aged 40 years and above with syncope whose diagnosis had remained uncertain after the initial evaluation or because no cause could be found or because contrasting findings were present duration, and position (supine or standing) of the carotid sinus massage Method of Symptoms Syncope recurrence rate reported in 12 studies of untreated and treated CSS patients plotted against the duration of the followup. In total, the studies accounted for 305 untreated and 601 treated patients. criteria for identification of mixed forms: arm cuff, Finapress Statistical analysis: recurrence, time to first syncope, syncope burden Europace. 2011;13(4):

5 The natural history of carotid sinus syncope and the effect of cardiac pacing syncopal recurrences are still expected to occur in up to 20% of paced patients within 5 years. Europace. 2011;13(4):

6 Heart 2009;96:347e351

7 The distribution of falls during the paced and non-paced periods hints at a placebo effect In favour of this hypothesis is the overall reduction in the number of falls in both 6- month periods compared with the pre-enrolment fall burden and the high number of subjects who experienced no falls at all during the course of the study (regardless of pacing mode status) Heart 2009

8 expectation effect expectation effect exists among open-label (unblinded) studies This expectation effect is a form of outcome ascertainment bias in which the knowledge of the presence of a pacemaker may lead to expectation of benefit on the part of both patients and clinicians.

9 multifactorial causes of syncope One or more potential multifactorial causes of syncope were present in 74% of CSS tilt table testing was positive in 63% patients Follow-up data were available in 141 patients. All these patients received advice on lifestyle measures in addition, preexisting hypotensive drug therapy was discontinued in 40 patients and reduced in 17 and 57 patients underwent pacemaker implantation Of those with a pacemaker, 18 had coexisting bundle branch block and 22 had bradycardia. D. Solari et al. Europace (2014)

10 from a practical point of view, a positive response to CSM should be considered diagnostic of the cause of syncope only in patients with a high likelihood of being affected by neurally-mediated syncope identified by relatively straightforward initial evaluation and clinical features, in accordance with the recommendations of current guidelines (high pre-test probability) Indeed, when competitive diagnosis of syncope are still present, the finding of a positive CSM might be unrelated to the cause of syncope. In these cases, the predictive value of CSM is lower and other tests are needed to confirm the mechanism of syncope Michele Brignole

11 conclusions Cardiac pacing is not effective in patients with predominant vasodepressor CSH Patients with asystole and a pronounced vasodepressor response, which remains after atropine, are classified as mixed. Pacemaker therapy has been shown to be less effective in this group than in the predominant cardioinhibitory group because of the important vasodepressor component In patients with predominant cardioinhibitory CSH and asystolic pauses lasting at least 6 s, cardiac pacing is indicated. About 75% of patients with symptomatic cardioinhibitory CSH corrected by atropine will have asystoles longer than 6 s. The remaining 25% have shorter-lasting asystoles and should be evaluated on an individual basis

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