From the Guidelines
Carotid sinus massage is the most appropriate initial investigation for a 62-year-old woman with recurrent syncopal episodes, normal electrocardiogram (ECG), normal pulse, and normal blood pressure (BP) 1.
Key Points
- The patient's age and presentation suggest a possible diagnosis of carotid sinus syncope, which can be evaluated with carotid sinus massage 1.
- Carotid sinus massage should be conducted in a controlled environment with ECG recording and resuscitation equipment available 1.
- Although tilt-table testing is an option for evaluating suspected vasovagal syncope, it is not recommended as a first-line investigation for this patient 1.
- Other investigations, such as ambulatory ECG recording or implantable event recorder, may be considered if the cause of syncope remains unclear after carotid sinus massage 1.
- Echocardiography may also be considered as an initial investigation, but it is not the most appropriate choice for this patient given her normal ECG and BP 1.
From the Research
Diagnostic Approach
The diagnostic approach for a 62-year-old woman with recurrent syncopal episodes, normal electrocardiogram (ECG), normal pulse, and normal blood pressure (BP) involves a step-by-step evaluation.
- Initial evaluation consists of careful history taking, physical examination including orthostatic blood pressure measurement and electrocardiogram 2.
- The initial evaluation alone may be diagnostic in some cases, but further investigations are often necessary 3.
Further Investigations
Further investigations may include:
- Tilt-table testing, which can be useful in diagnosing neurocardiogenic syncope 4, 3, 2.
- Electrophysiological testing, which can help diagnose cardiac causes of syncope 3, 5, 2.
- Carotid sinus massage, which can be used to diagnose carotid sinus syndrome 3, 2.
- Adenosine triphosphate (ATP) test, which can be used to diagnose sick sinus syndrome or atrioventricular block 2.
- Imaging studies, such as echocardiogram or angiography, may be necessary in some cases to rule out structural heart disease or pulmonary embolism 6, 5.
Selection of Tests
The selection of tests should be based on the pre-test probability inferred from the initial examination, and less invasive tests should be used first 2.
- The diagnostic yield of each test should be considered, with tilt-table testing and electrophysiological testing having higher yields in certain cases 3.