Approach Considerations
Carotid sinus hypersensitivity is an often undiagnosed cause of syncope in the elderly. The timely diagnosis and treatment of carotid sinus hypersensitivity can improve morbidity and prevent complications. [20]
Medical Care
Management of carotid sinus hypersensitivity (CSH) is based on the frequency, severity, and consequences of each patient's symptoms.
Most patients can be treated with education, lifestyle changes, expectancy, and routine follow-up.
A few individuals who have incapacitating and recurrent symptoms may need the following treatments:
Pharmacotherapy has been used to treat recurrent, symptomatic conditions. However, no single agent has been proven to provide long-term effectiveness in large-scale, randomized, controlled trials.
Permanent pacemaker implantation is generally considered an effective treatment for cardioinhibitory CSH and mixed forms of CSH.
Current American College of Cardiology/American Heart Association/Heart Rhythm Society clinical practice guidelines consider permanent pacing therapy to be a class I indication (ie, general agreement exists that the therapy is effective and useful) in patients with recurrent syncope caused by carotid sinus stimulation in the absence of any drug that depresses the sinus node or atrioventricular conduction. Permanent pacing is considered a class IIa indication in patients with recurrent syncope without clear, provocative events and with a hypersensitive cardioinhibitory response. Permanent pacing is discouraged in patients with a hypersensitive cardioinhibitory response to carotid sinus stimulation in the absence of symptoms. [21, 22, 23, 24]
The consensus is that dual chamber pacing (DDD, DVI, DDI) is optimal in the patients. However, VVI mode is also effective in preventing recurrent syncope in some patients. AAI and VDD modes are considered inappropriate.
Cardiac pacing has little or no effect on the vasodepressor type of CSH and may not reduce the frequency of falls in patients with CSH. Permanent pacing may diminish but not entirely eliminate the symptoms in CSH.
Volume maintenance can control the vasodepressor form of CSH, preventing syncopal episodes by maintaining adequate central volume. An individual without another cardiovascular disease should increase salt intake and drink more fluids containing electrolytes.
Surgical Care
Surgical denervation and radiological denervation of the carotid sinus nerve were techniques used previously, but they have been largely abandoned because of high complication rates.
Surgery remains an option for a patient with a neck tumor that is compressing the carotid sinus.
Consultations
Consult an electrophysiologist or cardiologist to rule out cardiac arrhythmia and evaluate the patient for pacemaker implantation.
Obtain a surgical consultation and evaluation if the patient has a neck tumor that is compressing the carotid sinus.
Activity
No general activity restrictions are necessary.
Patients should be aware of prodromal symptoms of presyncope or syncope. In such circumstances, immediately assuming supine posture is recommended to prevent syncope and/or falls.
Precipitating events, such as wearing tight neck collars or sudden rotating neck movements, should be avoided.
Long-Term Monitoring
Follow-up for carotid sinus hypersensitivity (CSH) should be based on the severity of symptoms and the treatment modality. Patients on any form of treatment require regular follow-up to monitor the effects of treatment versus the adverse effects of intervention. Follow-up for patients who rarely have symptoms may be on an as-needed basis.
