Safety and tolerability of Tilt Testing and Carotid Sinus Massage in the octogenarians

Head-up tilt testing in older syncope patients: a systematic review

BACKGROUND

In older syncope patients, medical histories are often less reliable due to retrograde amnesia and cognitive impairment. Therefore, additional tests may be needed to reach a diagnosis. We conducted a systematic review to evaluate positivity rates and safety of head-up tilt testing (HUTT) in these patients.

METHODS

We searched Medline and Embase for HUTT positivity rates and diagnoses in older syncope patients (mean age ≥ 65 years) vs. younger patients. Secondary outcomes were time to syncope (TtS) and adverse events (AEs). Risk of bias was assessed with a modified version of the QUADAS-2.

RESULTS

In total, 42 studies were included, with 12 378 older participants in total. Positivity rates varied widely [passive HUTT 0.0%-90.0%; isoproterenol (IPR)-HUTT 18.3%-64.0%; nitroglycerin-HUTT 30.1%-90.5%]. The majority of studies found no differences between older and younger patients. Specificity was high for all HUTT-protocols (85.5%-100%). TtS did not differ between older and younger patients, but was significantly longer in control subjects. Nitroglycerin-HUTT yielded the most diagnoses (median 64.2% vs. 23.7% for passive, P = .007, and 44.8% for IPR-HUTT, n.s.). Vasodepressive responses were more common than cardioinhibitory responses (median 54.9% vs. 9.1%) in older patients. AEs occurred in <6% of patients with passive/nitroglycerin-HUTT.

DISCUSSION/CONCLUSION

There is no consistent evidence that HUTT results differ between older and younger syncope patients. Nitroglycerin-HUTT yields the most diagnoses, whilst retaining a high specificity, and is safe to perform in older patients. Future studies should focus on the additional value of HUTT on top of the initial evaluation in these patients.

Carotid sinus massage in clinical practice: the Six-Step-Method

Carotid sinus massage (CSM) as integral part of cardiovascular autonomic testing is indicated in all patients > 40 years with syncope of unknown origin and suspected reflex mechanism. However, large practice variation exists in performing CSM that inevitably affects the positivity rate of the test and may result in an inaccurate diagnosis in patients with unexplained syncope. Even though CSM was introduced into medical practice more than 100 years ago, the method of performing CSM is still largely operator- and centre-dependent, while in many places, the test has been entirely abandoned. Here, we describe a standardized protocol on how to perform CSM, which basic monitoring equipment is necessary and why CSM is a safe procedure to perform. Our aim is to create a uniform approach to perform CSM. The new proposed algorithm, the Six-Step-Method, includes: (i) check history for exclusion CSM; (ii) turn head slightly contralaterally and posterior (see also explanatory video and poster provided as Supplementary material; (iii) palpation to identify carotid sinus location; (iv) massage for 10 s; (v) monitoring of blood pressure and heart rate to assess of the haemodynamic response type; and (vi) include time intervals between subsequent massages. Carotid sinus massage should be performed on both the left and right and in the supine and upright position. The recommended equipment to perform CSM consists of: (i) a tilt table in order to perform CSM in supine and standing position, (ii) a continuous blood pressure monitor or cardiac monitor, and (iii) at least two persons.

Carotid Sinus Massage During Head-up Tilt Testing Can Predict the Test Outcome: Implications for Its Use as a Screening Tool in Patients with Unexplained Syncope

Head-up tilt testing (HUT) has been used for decades in the work-up of patients presenting with syncope and a suspected reflex etiology. Different protocols have been used with varying sensitivity and specificity. The standard protocols are relatively long, with various maneuvers employed to elicit a response and potentially abbreviate the test. The role of carotid sinus massage (CSM) as a provocative maneuver has not been well studied. The objective of this study was to assess whether CSM could predict the outcome of HUT. Fifty consecutive patients who had been referred for head-up tilt table testing were prospectively enrolled in the study. All patients underwent an identical protocol that involved provocation with CSM both initially in the supine posture and at the end of 30 min of HUT. Seventeen out of 50 (34%) patients ultimately had a positive tilt table test result. Fifteen of these 17 patients had a significant vasodepressor response (symptomatic blood pressure drop of >20 mmHg) without significant bradycardia (heart rate of <50 bpm) during the initial CSM in the supine posture. Of the 33 patients with a negative tilt table result, none had a vasodepressor response to CSM. The sensitivity of CSM in detecting a patient who would ultimately have a positive tilt table test was 88.24% (95% confidence interval [CI], 63.56%-98.54%), while the specificity was 100% (95% CI, 89.42%-100.00%). CSM performed in the supine posture at the beginning of a tilt table test was highly sensitive and specific for the outcome of the test after completion of the entire protocol. Based on these findings, CSM may obviate the need for completion of the protocol for diagnostic reasons.

Syncope in the Emergency Department: A Practical Approach

Syncope is a common condition encountered in the emergency department (ED), accounting for about 0.6-3% of all ED visits. Despite its high frequency, a widely accepted management strategy for patients with syncope in the ED is still missing. Since syncope can be the presenting condition of many diseases, both severe and benign, most research efforts have focused on strategies to obtain a definitive etiologic diagnosis. Nevertheless, in everyday clinical practice, a definitive diagnosis is rarely reached after the first evaluation. It is thus troublesome to aid clinicians' reasoning by simply focusing on differential diagnoses. With the current review, we would like to propose a management strategy that guides clinicians both in the identification of conditions that warrant immediate treatment and in the management of patients for whom a diagnosis is not immediately reached, differentiating those that can be safely discharged from those that should be admitted to the hospital or monitored before a final decision. We propose the mnemonic acronym RED-SOS: Recognize syncope; Exclude life-threatening conditions; Diagnose; Stratify the risk of adverse events; Observe; decide on the Setting of care. Based on this acronym, in the different sections of the review, we discuss all the elements that clinicians should consider when assessing patients with syncope.

Syncope in older adults: challenges, approach and treatment

Syncope can have devastating consequences, resulting in injuries, accidents or even death. In our ageing society, the subsequent healthcare usage, such as emergency room presentations, surgeries and hospital admissions, forms a significant and growing socioeconomic burden. Causes of syncope in the older adult include orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, structural cardiac abnormalities, cardiac arrhythmias and conduction abnormalities. As stated in the recently published World Falls Guidelines, syncope in older adults often presents as falls, which is either due to amnesia for loss of consciousness, or pre-syncope leading to a fall, especially in those prone to falls with several other risk-factors for falls present. This difference in presentation can hinder the recognition of syncope. In patients with unexplained falls, or in whom the history comprises red flags for potential syncope, special attention to (pre)syncope is therefore warranted. When syncope is mistaken for other causes of a transient loss of consciousness, such as epileptic seizures, or when syncope presents as falls, patients are often referred to multiple specialists, which may in turn lead to excessive and unnecessary diagnostic testing and costs. Specialist services that are able to provide a comprehensive assessment can improve diagnostic yield and minimise diagnostic testing, thus improving patient satisfaction. Comprehensive assessment also leads to reduced length of hospital stay. Increasingly, geriatricians are involved in the assessment of syncope in the older patient, especially given the overlap with falls. Therefore, awareness of causes of syncope, as well as state-of-the-art assessment and treatment, is of great importance.

Recent Advances and Future Directions in Syncope Management: A Comprehensive Narrative Review

Syncope is a highly prevalent clinical condition characterized by a rapid, complete, and brief loss of consciousness, followed by full recovery caused by cerebral hypoperfusion. This symptom carries significance, as its potential underlying causes may involve the heart, blood pressure, or brain, leading to a spectrum of consequences, from sudden death to compromised quality of life. Various factors contribute to syncope, and adhering to a precise diagnostic pathway can enhance diagnostic accuracy and treatment effectiveness. A standardized initial assessment, risk stratification, and appropriate test identification facilitate determining the underlying cause in the majority of cases. New technologies, including artificial intelligence and smart devices, may have the potential to reshape syncope management into a proactive, personalized, and data-centric model, ultimately enhancing patient outcomes and quality of life. This review addresses key aspects of syncope management, including pathogenesis, current diagnostic testing options, treatments, and considerations in the geriatric population.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Bedside Carotid Sinus Massage for Syncope Evaluation With Bifascicular Block and First-Degree Atrioventricular Block

Symptomatic bifascicular block (BFB) with a reversible high-grade atrioventricular block (AVB) is an overlooked cause of syncope with differing diagnostic and therapeutic approaches. We present a case of a 79-year-old gentleman with multiple episodes of cardiac syncope. Initial electrocardiogram revealed a left bundle branch block and first-degree AVB worsened by bedside carotid sinus massage (CSM) obviating the need for electrophysiologic (EP) studies or continuous electrocardiographic monitoring for further evaluation. This case highlights the importance of CSM as a useful clinical tool in addition to EP studies and internal loop recorder (ILR) placement for assessment and appropriateness of permanent pacemaker (PPM) implantation. It also sheds light on the differing management protocols between EP studies and ILR evaluation versus empiric PPM implantation for patients with cardiac syncope secondary to BFB and AVB.

Case report: Recurrent syncope as initial symptom in a patient with neck lymphoma

Syncope may have many different causes, requiring careful identification. Recurrent syncope is uncommon as an initial symptom of neck lymphoma. Head and neck tumors involving the carotid artery cause syncope associate with carotid sinus syndrome. We report the case of a 72-year-old man who suffered from recurrent syncope due to compression of the right carotid sinus by diffuse large B-cell lymphoma and was successfully treated with immunochemotherapy. Syncope may be an early or sole sign of a neck or head tumor. We should be aware of the possibility of an underlying malignancy in patients with unexplained syncope after initial evaluation.

Syncope and the aging patient: Navigating the challenges

Syncope in the elderly patient is a common presentation and the most common causes are usually non-cardiac. Older adults however are more challenging dilemmas as their presentation is complicated by co-morbidities, mainly cardiovascular and neurodegenerative disorders. Frailty and cognitive impairment add to the ambiguity of the presentation, and polypharmacy is often a major modifiable contributing factor. Vasovagal syncope is a common presentation throughout life even as we age. It has a favorable prognosis and conservative management usually suffices. Vasovagal syncope in this population may be misdiagnosed as accidental falls and is frequently associated with injury, as is carotid sinus syndrome. The initial approach to these patients entails a detailed history and physical examination including a comprehensive medication history, orthostatic vital signs, and a 12-lead electrocardiogram. Further cardiac and neuroimaging rarely helps, unless directed by specific clinical findings. Head-up tilt testing and carotid sinus massage retain their diagnostic accuracy and safety in the elderly, and implantable loop recorders provide important information in many elderly patients with unexplained falls and syncope. The starting point in management of this population with non-cardiac syncope is attempting to withdraw unnecessary vasoactive and psychotropic medications. Non-pharmacologic and pharmacologic therapy for syncope in the elderly has limited efficacy and safety concerns. In selected patients, pacemaker therapy might offer symptomatic relief despite lack of efficacy when vasodepression is prominent. An approach focused on primary care with targeted specialist referral seems a safe and effective strategy.

Unexplained falls in the elderly

Falls are a geriatric syndrome affecting mortality, morbidity, and institutionalization. Falls are also the leading cause of unintentional injury and a common emergency department presentation. Physical and psychological issues may develop after falling, leading to increase in dependency and disability and their relative costs. The pathogenesis of falls is multi-factorial, being indeed the result of the interaction between increased individual susceptibility, high risk activities and environmental hazards. The patient should be evaluated for gait, standing balance, mobility, muscle weakness, cognitive status, osteoporosis risk, sensorial impairment, urinary incontinence, functional status, and for possible residential environmental hazards. It is also mandatory to obtain a full report of the circumstances and a careful therapeutic recognition. However not all falls are explainable. Indeed, retrograde amnesia and the frequent absence of a witness complicate history collection of falls in older adults. In this case, "the management of unexplained falls should be the same as that for unexplained syncope" as stated by the latest version of the European Society of Cardiology guidelines on syncope. In this context, the investigation of the cardiovascular autonomic nervous system and the use of implantable loop recorder have an increasing role. The present paper addresses the diagnostic approach to falls in older adults through a comprehensive multifactorial risk assessment and examines evidence and gaps on fall prevention strategies.

Complementary effectiveness of carotid sinus massage and tilt testing for the diagnosis of reflex syncope in patients older than 40 years: a cohort study

AIMS

Indications, methodology, and diagnostic criteria for carotid sinus massage (CSM) and tilt testing (TT) have been standardized by the 2018 Guidelines on Syncope of the European Society of Cardiology. Aim of this study was to assess their effectiveness in a large cohort which reflects the performance under 'real-world' conditions.

METHODS AND RESULTS

We analysed all patients who had undergone CSM and TT in the years 2003-2019 for suspected reflex syncope. Carotid sinus massage was performed according to the 'Method of Symptoms'. Tilt testing was performed according to the 'Italian protocol' which consists of a passive phase followed by a sublingual nitroglycerine phase. For both tests, positive test was defined as reproduction of spontaneous symptoms in the presence of bradycardia and/or hypotension. Among 3293 patients (mean age 73 ± 12 years, 48% males), 2019 (61%) had at least one test positive. A bradycardic phenotype was found in 420 patients (13%); of these, 60% were identified by CSM, 37% by TT, and 3% had both test positive. A hypotensive phenotype was found in 1733 patients (53%); of these, 98% were identified by TT and 2% had both TT and CSM positive.

CONCLUSION

The overall diagnostic yield of the tests in patients >40-year-old with suspected reflex syncope was 61%. Both CSM and TT are useful for identifying those patients with a bradycardic phenotype, whereas CSM has a limited value for identifying the hypotensive phenotype. Since the overlap of responses between tests is minimal, both CSM and TT should be performed in every patient over 40 years receiving investigation for unexplained but possible reflex syncope.

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN)

An expert committee was formed to reach consensus on the use of tilt table testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous events. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to the performance of (1) additional provocation tests, such as the active standing test, carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; and (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN)

An expert committee was formed to reach consensus on the use of Tilt Table Testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous ones. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to perform (1) additional provocation tests, such as the active standing test carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO₂ or neuro-endocrine tests; (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.

[Differential diagnostics of unclear syncope]

The clarification of syncope is a diagnostic challenge as possible causes often occur only intermittently. Therefore, a detailed and standardized anamnesis is essential as it 1) differentiates syncope from other transient losses of consciousness (TLOC) and 2) directly clarifies possible causes of syncope. The risk stratification plays a central and very important role in order to avoid unnecessary examinations in patients with benign syncope and to provide patients with life-threatening, mostly cardiac syncopal episodes with timely diagnostics and treatment. In cases where the cause of syncope is still unclear, a standardized approach is indicated using extended diagnostics, such as a tilt table examination, a carotid sinus pressure test, prolonged telemetric monitoring or clarification with an implantable loop recorder (ILR).

Usefulness of Tilt Testing and Carotid Sinus Massage for Evaluating Reflex Syncope

Thirty years ago Tilt Testing (TT) was described as a tool in the diagnostic work-up of vasovagal syncope; after its initial success, some flaws have become evident. The concept of hypotensive susceptibility has provided the test a new relevance, shifting from diagnosis only, to therapeutic management. Carotid Sinus Massage (CSM) was introduced at the beginning of the XX century; the technique has evolved over years, whereas the concept of carotid sinus syndrome (CSS) has remained unchanged and uncontested for more than half a century. Nowadays, CSS is a matter of debate, with new classifications and criteria coming on the scene. Recently, a common central etiological mechanism has been hypothesized for reflex syncope, manifesting as CSS, vasovagal syncope or both. In this context, TT and CSM acquire an important role in clinical practice, being essential for a complete diagnosis and treatment. Recalling their historical background, the present paper illustrates an actual interpretation of TT and CSM.

Stroke and Falls-Clash of the Two Titans in Geriatrics

Both stroke and falls are common conditions affecting the older adult. Despite stroke being considered a well-established major risk factor for falls, there remains no evidence for effective prevention strategies for falls specifically for stroke survivors. Previous observational studies evaluating falls risk factors in stroke have mainly been uncontrolled and found similar risk factors for stroke populations compared to general older populations. Specific risk factors, however, are likely to play a greater role in stroke survivors including unilateral weakness, hemisensory or visual neglect, impaired coordination, visual field defects, perceptual difficulties and cognitive issues. In addition, individuals with stroke are also more likely to have other associated risk factors for falls including diabetes, falls risk increasing drugs, atrial fibrillation, and other cardiovascular risk factors. While anticoagulation is associated with increased risk of intracranial bleeding after a fall, the risk of suffering a further stroke due to atrial fibrillation outweigh the risk of bleeding from a recurrent fall. Similarly, while blood pressure lowering medications may be linked to orthostatic hypotension which in turn increases the risk of falls, the benefit of good blood pressure control in terms of secondary stroke prevention outweighs the risk of falls. Until better evidence is available, the suggested management approach should then be based on local resources, and published evidence for fall prevention. Multicomponent exercise and individually tailored multifactorial interventions should still be considered as published evidence evaluating the above have included stroke patients in their study population.