Post on 29-Jan-2021
transcript
Il PM nella sindrome senocarotidea: tutto chiaro? Michele Brignole
Centro aritmologico e Syncope Unit – Lavagna
Carotid sinus
hypersensitivity Glossopharyngeal nerve Vagus
nerve
Carotid sinus nerve
Carotid sinus
Carotid Sinus Massage
CSM is the tool for evaluation of CS reflex arc function
CSS: syncope recurrence rate
%
Years
Blanc 84
Brignole 92
Brignole 92
Claesson 07
Claesson 07
Menozzi 93
Sugrue 86
Walter 78
Claesson 07
Claesson 07 Brignole 92
Brignole 92 Morley 82
Blanc 84 Stryjer 86
Sugrue 86
Crilley 97
Lopes 11
Pacemaker
No therapy
Europace 2011; 13: 462–464
Brignole et al. Am J Cardiol 1992; 69: 1039-1043
Cardiac pacing in CSS by Method of Symptoms
Study PM group
n/N
No PM group
n/N
Sugrue
1986
2/23 7/33
Brignole
1992 (a)
3/32 16/28
Claesson
2007
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)
Test for heterogeneity: p=0.39
Cardiac pacing in CSS by Method of Symptoms
Europace 2011; 13: 462–464
Actuarial estimates:
• 7% at 1 year
• 16% at 3 years
• 20% at 5 years
CSS: recurrence of syncope with cardiac pacing
Puggioni E et al. Am J Cardiol 2002; 89: 599
Critical issues in CSS
How to assess the magnitude of the
vasodepressor reflex (hypotensive
susceptibility) which is virtually present
in every CSS patient ?
Critical issues for pacing in CSS
• Lack of reproduction of symptoms during CSM, i.e., low specificity
• Mixed forms of CSS, i.e., important VD reflex
• Associated positivity of tilt testing, i.e., hypotensive susceptibility
Syncope is more likely to recur in presence of:
Carotid sinus syndrome: definitions
• Carotid sinus hypersensitivity (CSH):
asystole 3 sec and/or SBP fall 50 mmHg
(irrespective of symptoms)
Brignole M et al. Eur Heart J 2004 25, 2054–2072
Moya A. et al. Eur Heart J. 2009;30:2631–2671
A positive response induced by CSM does not
necessarily equate with clinical relevance
False positive responses of CSH !!!
272 participants sampled from a single general practice register who
underwent supine and upright CSM
(6.6%) (5%) = CSS
Pacing in elderly recurrent fallers with carotid sinus
hypersensitivity: a RCT crossover trial
Parry S, et al. Heart 2009
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)
Carotid sinus hypersensitivity (CSH)
Critical issues for pacing in CSS
• Lack of reproduction of symptoms during CSM, i.e., low specificity
• Mixed forms of CSS, i.e., important VD reflex
• Associated positivity of tilt testing, i.e., hypotensive susceptibility
Syncope is more likely to recur in presence of:
Results: CI vs Mixed (atropine test)
Solari D et al. Circ Arrhythm Electrophysiol 2014
Brignole et al. Am J Cardiol 1992; 69: 1039-1043
Cardiac pacing in CSS by Method of Symptoms
Europace (2011) 13, 572–575
Recurrence CI: 13% Recurrence Mixed: 38%
Critical issues for pacing in CSS
• Lack of reproduction of symptoms during CSM, i.e., low specificity
• Mixed forms of CSS, i.e., important VD reflex
• Associated positivity of tilt testing, i.e., hypotensive susceptibility
Syncope is more likely to recur in presence of:
Am J Cardiol 1995; 76: 720
Non-CI forms
CI form
Negative or not performed
Recurrence of syncope according to tilt test results
Log rank: p=0.008
Solari d et al. Europace 2014; 16: 928-934
Perspectives
• Quantification of VD component is clinically
relevant, since PM therapy is less effective when
the VD effect is large (vs CI)
• Mixed form is an independent predictor of
symptom recurrence with PM therapy
• Dominant VD forms benefit from withdrawal of
hypotensive drug therapy