Hipersensibilidad del seno carotídeo. Una causa olvidada de síncope y caídas en el adulto mayor. Abstract. Resumen: El síndrome del seno. El síndrome del seno carotídeo se clasifica de acuerdo con el tipo de .. Solo el síncope asociado con hipersensibilidad del seno carotídeo. descartar otras causas de síncope, tales como enfermedad carotidea oclusiva, hipersensibilidad del seno carotideo o hipotensión ortostática.
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Hypersensitivity of carotid sinus. A forgotten cause of syncope and falls in the elderly. Its physiopathology is not clear even if it has many common points with neutrally mediated syncope. The diagnosis is usually clinical and the carotid sinus massage confirms it by reproducing the symptoms when it induces longer than three second asystole or blood pressure drops higher than 50 mmHg.
Its treatment has many controversial points and the options are limited when it comes to the vasodepressor variety. In the cardio-inhibitory variety, the most accepted treatment is a pacemaker implant, nonetheless, the recurrence rates still high. El tratamiento presenta muchos puntos de controversia y hay opciones limitadas cuando se trata de la variedad vasodepresora.
Carotid sinus hypersensitivity CSH is included within the reflex or neurally-mediated hipersensibiliad. Patient with carotid sinus syndrome. Massage is applied in the right carotid sinus for five seconds in decubitus and a pause of more than 12 seconds with dizziness and fainting is caused. The incidence of the syndrome The syndrome is predominant in men 2: Among patients with syncope, it is common to have several co-existing dys-autonomic reflexes.
A study by the group of Brignole in one-hundred patients, found that 79 of them had a positive response to some of the different provocative maneuvers tilt testing, carotid sinus massage, eye compression.
Our group has found 22 subjects in the last six years that had symptoms associated to changes in the heart rate or blood pressure induced by hipesrensibilidad sinus massage. Only eleven patients had the diagnostic criteria defined by the guidelines reduction in systolic BP higher than 50 mmHg and or sinus pauses longer than three seconds. Among these eleven patients, the average carotdeo is Table I shows the main demographic and clinical characteristics of the patients.
Sfno of patients with carotid sinus hypersensitivity.
Sнncope: electrocardiograma y pruebas de funciуn autonуmica – Medwave
The main autonomic components are a sympathetic withdrawal that induces vasodepression -hypotension- and a vagal reflex responsible for the cardioinhibitory response. Apparently these phenomena are related with an abnormal function of the baroreceptors and to degenerative changes in the spinal medulla.
The chain of events seems to initiate with a drop of the cardiac output induced by bradycardia that is followed by a reduction of the total peripheral vascular resistance, even if the sympathetic withdrawal is immediate to the carotid sinus massage, regardless if it is performed in decubitus or standing up. This implies an incapacity to maintain the brain blood flow in face of a hypotensive challenge and it manifests itself as a higher frequency of syncope spells or falls.
The first descriptions of the carotid sinus hypersensitivity come from Ibn Sina Avicenna in the 11th century, 10 nonetheless, the correlation between the heart rate or blood pressure changes with the carotid sinus massage was made in In that year, J. Ina comment about a work from Wenckebach, related the use of tight collars with syncope.
The main cases described were clergy men that had syncope when leaning forward or doing other movements with those high tight collars. Usually the patients have syncope spells without warning or with minimum previous symptoms. Many times it is related to some action that stimulates the carotid sinus such as turning the head, lift the chin, shave or adjust a tie.
A significant amount of patients mention falls rather than syncope, as their main symptom, and it is common that the drop attacks are actually a form of CSH. The diagnosis of the CSS is clinical and is supported by the reproduction of the signs and symptoms when crotideo sinus massage is applied to the patient. The massage has to be applied in the supine position on both sides of the neck. Ideally, the CSM should craotideo made in hipersensibilisad hospital or in a medical facility capable of solving any possible complication of the test.
Many syncope units perform the CSM in the same space allocated to the tilt test, since they carrotideo a readily available EKG and continuous blood pressure monitoring system. There a firm but gentle pressure has to be applied to avoid any occlusion of the carotid artery. Both sides of the neck have to be stimulated for ten seconds.
Hipersensibilidad del seno carotídeo. Una causa olvidada de síncope y caídas en el adulto mayor
Since the bradycardia component is eliminated, the contribution of the blood pressure fall to the symptoms can be caroticeo more accurately. Carotid sinus massage has some relative contraindications, as the presence of carotid murmurs, and absolute ones such as ischemic transient attacks, stroke or myocardial infarction the three months prior to the evaluation.
According to Sutton, the contraindication is probably more related to the changes in autonomic function induced by those conditions that can induce false results of the test than to a real danger of the CSM. In our series, in the cardioinhibitory group, cel average pause duration was 5. In four patients the pause was induced while applying massage to the right side of the neck, which is the first stimulated side. In two subjects the pause was induced while massaging the left side and in one patient it was induced while massaging the right side of the neck in a standing position.
Only one of the patients with the vasodepressor variety showed it in the standing position. In this form of the syndrome, a double chamber pacemaker seems the most straightforward option. Apparently, the first cause for this skepticism was the fear to practice a carotid sinus massage as a diagnostic maneuver, and in second place, the recurrence rate. There is still some controversy about the pacemaker indication, 18 – 21 but nonetheless, it appears in the recent pacing European guidelines as a class I indication with a B level of evidence.
The physician must discuss this matter with the patient in order carotidwo optimize the treatment in every case. As is common among patients with the vasodepressor variant of the neurocardiogenic syncope, the patients with CSS have less treatment options.
This is a serious limitation since it is an older population with higher risk of trauma associated to syncope or falls. A general recommendation is to increase the ingestion of fluids approximately two liters per dayand if possible, also increase salt in the diet.
Unfortunately, many of these patients also have coexisting arterial hypertension or other co-morbidities that might preclude an increased salt intake or might contra-indicate some of the medications that will be mentioned further on. Other general measures such hipersensihilidad exercise have not proven any benefit. It is important to reach equilibrium between the drugs that reduce blood pressure and those that increase it, and in many cases, it will be necessary to hipersnsibilidad the drl treatment.
Some authors suggest that the blood pressure control might be even more permissive than the one suggested in the guidelines to avoid the hypotension episodes.
Some studies have used fludrocortisone or midodrine to avoid hypotension among these patients, but the main problem remains hypertension. A recent study has used droxydopa, a synthetic aminoacid that converts to norepinephrine, as a treatment option in the neurologic hioersensibilidad hypotension syndromes.
These two patients had the longest pauses Twelve seconds and 5. The other patients with predominant cardioinhibition rejected the device when we made clear to them that it would only avoid the bradycardia-mediated events but not the hypotension-mediated ones.
During the current mean follow-up period The clinical presentation might be hipersensibillidad, and even if many times the cardinal symptom is syncope, there are cases in which it is not present. Once the diagnosis is confirmed by the carotid sinus massage, the treatment must be directed towards a reduction of its possible consequences. Regarding the patients with the cardioinhibitory variety, pacing is useful although there is a hiperssensibilidad recurrence rate due to the co-existence of the vasodepressor component.
The pharmacological options are limited by a lack of experience and by other co-morbidities, the most common, arterial hypertension. Our series shares the general characteristics described by other authors, but it is worthy to have more hipersensiblidad information in order to define if there are local differences. It is also important to consider that this pathology is an important factor that compromises quality of hipersenskbilidad among elderly adults and that it can be associated or confounded with other forms of dysautonomic reflexes known in elderly Mexicans.
Guidelines for the diagnosis and management of Syncope Version Eur Carotieeo J ; 30 Progress in understanding and management. Global Cardiology Science and Practice Clinical context and outcome of carotid sinus syndrome diagnosed by means of the “method of symptoms”. Brignole M, Menozzi C. Eur J Card Pacing Electrophysiol.
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Carotid sinus hypersensitivity is common in patients presenting with hip fracture and unexplained falls. Aerobic training in older adults with type 2 diabetes and vasodepressive carotid sinus hypersensitivity.
Aging Clin Exp Res. Droxidopa in neurogenic orthostatic hypotension.