CORRESPONDENCE: LETTER TO THE EDITOR
Reply
David G. Benditt, MD* and
John T. Nguyen, MD, MPH
* University of Minnesota Medical School, Cardiovascular Medicine, Cardiac Arrhythmia Center, 420 Delaware Street SE, MMC 508, Minneapolis, Minnesota 55455 (Email: bendi001{at}umn.edu).
We appreciate the opportunity to respond to the letter regarding our paper (1). Dr. Kapoor, in taking note of our recent communication related to therapy of syncope (1), principally addresses a diagnostic issue related to identifying carotid sinus hypersensitivity (CSH). In essence, he highlights the importance of undertaking carotid sinus massage (CSM) with the patient in an upright posture if CSM in the supine patient is nondiagnostic. We agree with this advice. However, several points merit consideration. First, the "pearl" is not new, although perhaps worthy of repetition in the U.S. where European Society of Cardiology syncope practice guidelines remain underappreciated (2). Specifically, since their initial publication (an updated third iteration is found in the September 2009 issue of the European Heart Journal), European Society of Cardiology syncope guidelines have highlighted the value of CSM being performed with the patient in the upright position (2). For instance, the 2001 version (based on citations dating back to 1983 [3]) states that "increasing importance has been given to...massage in the upright position, usually using a tilt table. Other than a higher positivity rate compared with supine massage only, the importance of performing upright massage is...evaluating the magnitude of the vasodepressor component..." (2). Second, the method by which one undertakes CSM (whether the patient is supine or upright) and contraindications to its performance are not addressed by Dr. Kapoor; their understanding by clinicians using this procedure is crucial and are in the guidelines (2). Finally, and most important, Dr. Kapoor does not distinguish CSH from carotid sinus syndrome (CSS). CSH is identified by certain well-accepted abnormal responses during CSM (2) and is a relatively common finding during examination of older individuals. However, demonstrable CSH does not equate to a diagnosis of CSS (4). Only if CSH is clinically established to be responsible for syncope in a given individual should it be considered a relevant observation and thereby lead to a diagnosis of CSS with consequent initiation of targeted therapy. Establishing the connection between CSH and CSS demands careful assessment of the medical history and exclusion of other competitive diagnoses.
In summary, we substantially concur with Dr. Kapoor's comment. However, clinicians must remain aware that finding CSH in patients with syncope may be misleading (1,2,4). We again emphasize a cautionary note provided in our recent article (1): "The physician should not too quickly accept an observed abnormality to be causal in a given individual."
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References
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1. Benditt DG, Nguyen JT. Syncope: therapeutic approaches J Am Coll Cardiol 2009;53;:1741-1751.[Abstract/Free Full Text]2. Brignole M, Alboni P, Benditt DG, et al. Task Force on Syncope, European Society of Cardiology. Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J 2001;22:1256-1306.[Abstract/Free Full Text] 3. Brignole M, Sartore B, Prato R. Role of body position during carotid sinus stimulation in the diagnosis of cardioinhibitory carotid sinus syndrome [in Italian] G Ital Cardiol 1983;13:69-72.[Medline] 4. Benditt DG, Brignole M. Syncope: is a diagnosis a diagnosis? J Am Coll Cardiol 2003;41:791-794.[Free Full Text]
Related Article
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Carotid Sinus Hypersensitivity: A Diagnostic Pearl
- John R. Kapoor
J. Am. Coll. Cardiol. 2009 54: 1633.
[Full Text]
[PDF]
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