The carotid sinus syndrome: a frequently overlooked cause of syncope in the elderly

Exaggerated carotid sinus reflexes may account for alterations in consciousness responsible for significant disability and injury in elderly patients. Nonspecificity of symptoms and concomitant medical conditions frequently delay diagnosis and therapy. During a recent 9-year period, 82 patients were identified as having symptomatic carotid sinus hypersensitivity (CSH). Fifty-nine patients described complete syncope, 73 patients had multiple syncopal or near-syncopal episodes, and 40 patients related cervical pressure or motion as provocative events. Electrophysiologic testing demonstrated that 47% had cardioinhibitory CSH, 26% had vasodepressor CSH, and 27% had combined vasodepressor and cardioinhibitory CSH. The mean follow-up period of all patients was 36 months. Surgical therapy included ventricular demand pacemaker implantation in 33 patients and carotid sinus denervation in seven patients. Medical therapy was used in 32 patients, 11 mildly symptomatic patients were not treated, and 3 patients had carotid sinus irradiation. Pacemaker implantation relieved symptoms in 53%; however, 11 patients (33%) had significant postoperative complications. Carotid sinus denervation relieved symptoms in 86%, medical therapy in 54%, and carotid sinus irradiation in 33% of patients. Because of its demonstrated effectiveness in all variants of CSH and negligible perioperative morbidity, carotid sinus denervation should be offered to acceptable operative candidates when the diagnosis of CSH is confirmed.