Outcomes of permanent pacemaker implantation for Carotid Sinus Hypersensitivity in a District General Hospital with a Falls Fits Faints and Funny Turns Clinic.  

SMJ 2002: 47(6) 128-131

P. Malkanthi Karunaratne*, Paul A Broadhurst #, Carol A Norris*.

* Department of Medicine for The Elderly,  # Department of Medicine (Cardiology)

Borders General Hospital, Melrose, Roxburghshire, TD6 9BS.

 

Address for correspondence and reprints:

Dr. C. A. Norris.

Consultant Physician,

Department of Medicine for The Elderly,

Borders General Hospital, Melrose,

Roxburghshire, TD6 9BS.

Tel. 01896 826000

Fax. 01896 823476

Email: joy-Anderson@borders.scot.nhs.uk

 

Abstract

 Permanent pacemaker implantation is considered for Carotid Sinus Hypersensitivity with asystolic pause of  > 3 seconds during carotid sinus massage, with or without associated systolic blood pressure drop of  > 50 mmHg.

Aims:  To assess the outcome of treatment with dual chamber permanent pacemaker implantation for carotid sinus hypersensitivity in a district general hospital and to compare our practice with available national data.

Methods: Patients presenting with syncope, dizziness or unexplained falls were initially  assessed  as outpatient and  investigations, commonly cardiovascular were performed including tilt table test with carotid sinus massage to look for carotid sinus hypersensitivity, vasovagal syncope and  postural hypotension. A retrospective analysis was performed on patients who had pacemaker implantations for carotid sinus hypersensitivity.

Results:  50 pacemaker implantations were performed, 14 (28%) were for carotid sinus hypersensitivity. Mean follow-up period was 10 months. Age range was 56-88 (mean = 71.9) years. In the eighteen months prior to pacemaker implantation, 71.4% of patients had syncope, 64% dizziness and 50% had unexplained falls. Following pacemaker implantations, only 2 (14.3 %) had symptoms.  Scottish national figures show 13.6% of all new pacemaker implants were for carotid sinus hypersensitivity, and in district general hospitals this was 16%.

Conclusions: Health benefits for patients presenting with syncope dizziness and falls can be achieved by cardiovascular investigations including tilt table testing. We have shown  carotid sinus hypersensitivity is successfully treated with  pacemaker implantation  in a district general hospital setting and this type of clinic has an impact on the rate and type of new pacemaker implantation.

Key words: Syncope, dizziness and falls, Carotid sinus hypersensitivity, Pacemaker, District general hospital

 

Introduction

  Carotid sinus hypersensitivity (CSH) is a frequently overlooked cause of syncope, dizziness and falls in older people 1 and is diagnosed in a subject with otherwise unexplained symptoms when up to five seconds of carotid sinus massage (CSM) produces an asystolic pause exceeding three seconds (cardio-inhibitory), a fall in systolic blood pressure (BP) exceeding 50mmHg (vaso-depressor) or a combination of the two (mixed). 1 Dual chamber pacing is now accepted as treatment of first choice for syncopal patients with pure or a predominant cardio-inhibitory response to CSM. 2, 3 Recurrent symptoms after ventricular demand pacing for carotid sinus syndrome has been previously reported 4, 5, 6 and has been attributed to the vasodepressor response. 7, 8

Most falls and syncope clinics with Tilt Table Test (TTT) facilities provide an age related segregated service. Our facility provides this service for all ages in a focussed setting.  Neuro-cardiovascular assessment in a focussed setting has increased the diagnostic yield in an urban district general hospital. 9  In one study of syncope in the elderly the history and physical examination led to 40% of the diagnosis that could be assigned. CSM, postural BP measurements together with accurate history, examination, surface ECG, appreciably increased  diagnostic yield up to 70%.1  5-10% of cases CSM is only positive in upright position. Additional diagnostic yield of CSM is 35%. Sensitivity of TTT is approximately 70%, specificity is 89 – 100% and reproducibility is 70 – 80%. Sensitivity and specificity of any given protocol will vary as degree of tilt, duration and the use of  isoprenaline or glyceryl trinitrate varies.10 The specificity of TTT must be considered in the light of physiological sequences that led to syncope.1

 

Final diagnosis of CSH was found in 45% of over 65 years olds presenting with syncope.1 Significant overlap of presenting symptoms of syncope, dizziness and falls was noted  in patients paced for carotid sinus syndrome who were asymptomatic at  2 years.11

 

 A group of 42 patients who had permanent pacemaker implantation for CSH over a 34 month period had shown dual chamber pacing is an effective treatment in older patients with recurrent falls, dizziness and syncope in whom cardio-inhibitory CSH is found.11  Mean follow-up period following permanent pacemaker implantation was 10 months. In this study 84% of patients had no further syncope, minor symptoms persisted in 40% and symptoms unchanged in 22%.Findings from a  “Syncope and Falls” clinic in Newcastle has indicated the impact of its  recognition on  pacemaker treatment of carotid sinus syndrome in a regional hospital setting.12

 

Our aim was to assess symptom improvement following permanent pacemaker implantation for CSH in our pacemaker facility and compare our pacing rates for CSH with national figures to see if there is an impact on the pacing rate in a district general hospital level as this has not been previously demonstrated.

 

Methods

The Department of Medicine for the Elderly at the Borders General Hospital serves a population of 106,000. A Falls Fits Faints and Funny Turns Clinic with TTT service is integral in the department. Details of patient assessments are entered in a clerking proforma. A retrospective study of the clinic (1997/1998) had shown a high diagnostic yield of 98%. 66% of the TTT (number performed = 57) were positive, 41% were for CSH. Final diagnosis of CSH was made in 12% of the 182 clinic patients. Permanent pacemaker implantation in this hospital commenced in January 1999 and also entered on to a pacemaker data base.  Prior to 1999 our patients were sent to the regional centre for  pacemaker implantation.

 

All age groups presenting with syncope, dizziness and falls are assessed in the same clinic. Full medical assessment followed by required investigations, mostly cardiovascular including TTT with CSM are arranged for the above patients. We follow the tilt table protocols of  the Cardio-vascular Investigation Unit in the Royal Victoria Infirmary, Newcastle.10   During TTT, if the patients do not have contra indications, CSM is performed.13, 14, 15, 16, 17  The carotid sinus is located between the superior border of the thyroid cartilage and the angle of the mandible, and the site of the maximum impulse is found with the patient recumbent and with the head in a neutral position between neck flexion and extension.

 

Contraindications to carotid sinus massage:

1.   Audible carotid bruit (consider carotid doppler) or known carotid stenosis

2.        Evidence of severe cardiac arrythmias or past history of ventricular tachycardia or  ventricular fibrillation.

3.   Recent transient ischaemic attack or stroke (within 3 months)

4.   Recent myocardial infarction (within 3 months)

(Caution with previous stroke - wait until carotid doppler results are known, if previous anterior circulation stroke / widespread arterial disease /multiple vascular risk factors)

 

Five seconds of CSM is performed on the right followed by the left when the patient is in a supine position. If necessary, the patient is then tilted upright to 70 degrees and CSM is repeated. Beat to beat BP is monitored using the Finapres finger BP monitor and a continuous electrocardiographic tracing is also recorded.

 

Definitions of carotid sinus hypersensitivity were used as follows:

·         Cardio-inhibitory: asystolic pause of more than 3 seconds during CSM.

·         Vaso-depressor: systolic BP drop of 50 mmHg or more after CSM.

·         Mixed: above both present at the same time.

 

 

Vasovagal Syncope 

Head-up Tilt for 70 degrees is performed with the aid of the tilt table for 20 minutes followed by GTN (Glyceryl Trinitrate) spray and continued monitoring for further 20 minutes.

The definition of vaso-vagal syncope was as follows :

·         Type 1: Mixed - Heart rate falls during syncope but ventricular rate is never less       that 40 beats per minute (bpm) or falls to less than 40 bpm for less than 10 seconds with or without asystole  of less than 3 seconds . BP falls prior to fall in heart rate.

·         Type 2A: Cardio-inhibitory- Heart rate falls at syncope to a ventricular rate of less than 40 bpm for more than   10 seconds or asytole occurs for more than 3 seconds.     BP again falls prior to the   heart rate fall.

·         Type 2B: Cardo-inhibitory - Heart rate falls at syncope to a ventricular rate less than 40 bpm for more than 10  seconds or asytole   occurs for more that 3 seconds.  BP falls to hypotensive levels (<80 mmHg systolic) only at or after   the onset of rapid and severe heart rate fall as previously defined.

·         Type 3: Vasodepressor -   Heart rate does not fall more than 10% from its peak at the time of syncope.    BP   falls to precipitate syncope.

 

Postural hypotension

After being in a supine position for 10 minutes patient is asked to stand actively without any support. BP is monitored using Dinamap BP monotor every 30 seconds for further 2 minutes. Systolic BP drop of > 20 mm Hg is considered as postural hypotension.

Patients with a positive cardio-inhibitory or mixed CSH were referred to a cardiologist for permanent pacemaker implantation. Dual chamber pacemakers were implanted for CSH group with a rate hysteresis (50-90 beats/min) or rate drop algorithm.

These patients were then followed-up in the pacemaker clinic and some in the syncope and falls clinic after  pacemaker implantation. Symptoms up to 18 months prior to pacemaker implantation, and TTT were analysed. Patients who had undergone permanent pacing over a period of 18 months (January 1999 – July 2000)  were extracted from the pacemaker database and those with CSH  were followed up by way of a questionnaire in which patients were asked to report symptoms such as loss of consciousness, dizziness or falls  since pacemaker implantation and if their confidence and general health had improved.  The questionnaire was posted to the people who were unable to be contacted by phone or had not visited the clinic.

 

Questionnaire sent to the patients:

 

1. Have you had any of the following since pacemaker insertion?                                        

Loss of conciousness  YES                    NO            HOW MANY

Dizziness                        YES                    NO            HOW MANY

Unexplained falls           YES                   NO            HOW MANY

2. Do you feel your general health has improved since pacemaker insertion?

                                               YES                   NO

  3. Do you feel your confidence has improved since pacemaker insertion?

                                               YES                   NO

 

Results were compared with the British Pacing Electrophysiology Group (BPEG)  pacemaker  data base,17  both in the United Kingdom (UK) and in Scotland.

 

Results

During the 18 month period, 50 patients underwent pacemaker implantation out of which 28% (n =14) were for CSH (Table I). Mean follow up period was 10.66months.All the above patients were mentally alert, independent and self- caring.  Male to female ratio was 50% in the CSH group and 53% female patients had pacemaker implantation for other indications. Age range of the CSH group was 56-88  (mean = 71.9) years and for other indications was 51-97 (mean = 77.3) years.   In the CSH group, 71.4% (n = 10) of patients had syncope, 64.3% (n = 9) had dizziness (or presyncope) and 50% ( n = 7) had unexplained falls prior to pacing. 10 out of 14 patients (71%) had multiple symptoms with overlap of syncope, dizziness or falls prior to  presentation.

TTT results of this group showed 6 (42.9%) to be of cardio-inhibitory and 8 (57.1%) to be of mixed CSH. On TTT, Positive supine CSM was noted in 9 (64.3%) and positive on 70 degree tilt in 5 (35.7%). Right CSM was positive in 5 (35.7%) and left was positive in 9 (64.3%). Mean asystolic pause was 4.53 seconds (range 3.6-8.8). Symptom reproduction during the asystolic pause was noted in 9 (64.3%) patients.

 

All 14 patients were in sinus rhythm prior to pacemaker implantation. Dual chamber pacemakers were implanted in all 14 (100%) patients with CSH whereas 44% of  patients with other  indications for pacemaker implantation, received dual chamber devices. The rest received single chamber pacemakers (VVI = 17, VVIR = 3).  Following pace maker implantation for CSH, none of the patients had syncope or falls and only 2 (14.3%) patients had occasional dizziness (Figure 1). All 10 patients with syncope, all 7 patients with falls and 7 out of 9 patients with dizziness completely improved.

All 14 (100%) reported improvement in confidence and general health following permanent pacemaker implantation.  Two patients died due to unrelated causes five and nine months after pace maker implantation. Their post- pacemaker implantation status was obtained from hospital case notes. One patient in the CSH group developed wound infection, one month after pacing, successfully treated by debridement.

Our implant rate for CSH is higher than in the United Kingdom and Scotland as well as Scottish regional and Scottish district general hospital pacing rates but similar to centres with syncope and  falls investigational facility (Table II).

 

Discussion

Falls, dizziness and syncope commonly overlap in presentation and prevalence increases with age.1, 11  Amnesia for syncope is present in about a third of patients emphasising its relevance to falls.1, 11, 19  Carotid sinus syndrome is associated with appreciable morbidity, half of patients sustaining injuries during syncope while fractures (predominately fracture neck of femur) were sustained in 25%.1 Cadiovascular investigation in dedicated syncope and falls facilities can give a high diagnostic yield.1, 9, 11, 20  In such clinics, CSH is easily diagnosed by CSM. In our Falls Fits Faints and Funny Turns Clinic, following cardiovascular investigations CSH is diagnosed with a high positive yield. Our facility has shown a diagnostic yield of 98%. 86% of the group became asymptomatic in our study following dual chamber permanent pacemaker implantation. This group of patients also reported improvement in their general health and confidence demonstrating substantial health gain in investigating patients with  symptomatic CSH.

Limitations of our study were small size, retrospective nature and the use of a patient questionnaire which was not validated.

A dedicated syncope clinic in a large teaching hospital has shown an impact on pacemaker implantation rate. Our results from a district general hospital has also shown CSH to be a relatively common indication for pacing when compared to the UK and Scottish national figures, both in regional and district general hospital settings.

Dedicated syncope and falls clinics identify patients with carotid sinus hypersensitivity and pacemaker therapy helps in their subsequent management.  This can be achieved in a district general hospital setting.

 

Acknowledgements

We gratefully acknowledge Ms Tracy Hume, Sister Maria Drover, Mrs Morag Young and Mrs Arline Mitchell for their support towards the study. Our thanks to Dr. David Cunnigham, Database Manager, National Pacemaker Database for help with obtaining pacemaker data.

 

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