Carotid sinus hypersensitivity and carotid sinus

syndrome
Author: David Benditt, MD
Section Editor: Peter Kowey, MD, FACC, FAHA, FHRS
Deputy Editor: Susan B Yeon, MD, JD, FACC

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Jul 2021. | This topic last updated: Aug 19, 2020.

INTRODUCTION

The carotid baroreceptors, located bilaterally in the neck near the bifurcation of the
internal and external carotid arteries, play an important physiologic role in heart
rate and blood pressure control. Carotid sinus hypersensitivity (CSH) consists of
the observation that stimulation of the carotid artery baroreceptors results in a
greater than expected fall in heart rate and drop in blood pressure. In such cases,
carotid baroreceptor stimulation (eg, mechanical forces such as may occur with
turning of the neck or looking upward) results in vagal activation and/or
sympathetic inhibition. CSH is not a clinical diagnosis per se but is a potential
cause for symptoms in some patients, at which time the condition is termed
carotid sinus syndrome (CSS).

CSH tends to be observed mainly in older individuals (predominantly males) who

have atherosclerotic vascular disease. However, CSH may also be observed in
individuals who have acquired abnormalities of the structure of the neck (eg, prior
neck surgery and/or irradiation) or tumors in the region of the carotid sinuses.
CSH is a relatively common observation but only an infrequent cause of
spontaneous symptoms. Thus, CSH does not require treatment unless it is
deemed to be causing symptoms (such as syncope, near-syncope, or unexplained
falls in older patients), resulting in CSS.

CSH and CSS will be reviewed here. Other types of reflex syncope, including
vasovagal syncope, as well as general discussions of the pathogenesis, etiology,
and evaluation of syncope, are discussed separately. (See "Reflex syncope in
adults and adolescents: Clinical presentation and diagnostic evaluation" and
"Syncope in adults: Epidemiology, pathogenesis, and etiologies" and "Syncope in
adults: Clinical manifestations and initial diagnostic evaluation".)

DEFINITION

There is not a universally accepted definition of what constitutes an abnormal

response to carotid baroreceptor stimulation, resulting in carotid sinus
hypersensitivity (CSH). The most commonly accepted definition is presented in
the 2017 American College of Cardiology/American Heart Association/Heart
Rhythm Society (ACC/AHA/HRS) and 2018 European Society of Cardiology
syncope guidelines, which consider an abnormal value to be heart rate (HR)
pauses >3 seconds and a drop of systolic blood pressure (BP) >50 mmHg [1,2].

However, others believe that the scientific basis for the stated criteria is unclear
and that they criteria are too sensitive and nonspecific. Some have proposed that
cerebral hypoperfusion for >5 seconds with the patient in an upright position be
utilized [3]. An even more stringent requirement, advanced especially in Europe, is
that CSH should result in reproduction of symptoms with the patient in the upright
posture. Our experts agree that a five-second pause induced by carotid sinus
massage is indicative of CSH and in a symptomatic individual is diagnostic of CSS
in the absence of a reasonable alternative diagnosis. In any case, regardless of the
chosen definition, it is paramount to observe changes in HR and BP. (See 'Test
results' below.)
In contrast to CSH, there is general consensus in the definition of carotid sinus
syndrome (CSS), which reflects that a patient's symptoms (eg, lightheadedness,
syncope, etc) directly result from CSH.

PREVALENCE

CSH is a laboratory observation/physical finding, not a clinical syndrome; it

appears to be common in older patients, occurring in 14 percent in one
prospective series of unselected syncope patients and in up to 50 percent of
patients with syncope unexplained by initial screening [4-7]. Consequently, the
presence of CSH alone, without symptoms, is inadequate to establish a diagnosis
basis for symptoms. Reproduction of symptoms by carotid sinus massage
provides more solid evidence of a correlation with symptoms and is suggestive of
CSS. However, older people are more likely to have an abnormal CSH response
even if they do not clearly have symptoms due to CSH [3,8,9].

CSS as a cause of syncope is relatively rare, accounting for only approximately 1

percent of syncope cases [10]. CSS is almost entirely restricted to older male
patients (>65 years). A careful history taking is crucial to establishing the
diagnosis.

PATHOPHYSIOLOGY

The carotid baroreceptors, specialized tissues sensitive to mechanical pressure,

are located bilaterally approximately at the bifurcation of the carotid arteries.
These baroreceptors are physiologically important for blood pressure and to a
lesser extent heart rate control, acting through a reflex arc that incorporates
afferent signals to the cardiovascular control centers in the midbrain and efferent
parasympathetic and sympathetic neural pathways to the heart and peripheral
blood vessels. Hypersensitivity of the carotid sinus reflex arc (CSH) may occur in
some persons.
The carotid sinus reflex arc is composed of an afferent limb arising from
mechanoreceptors in the internal carotid artery and terminating in the vagal
nucleus and the vasomotor center in the medulla. The efferent limb has two
components:

● Innervation of the sinoatrial and atrioventricular (AV) nodes via the vagus nerve
and the parasympathetic ganglia.

● Inhibition of sympathetic nervous tone to the heart and blood vessels.

The site of the abnormality that causes the hypersensitive response in patients
with CSH has not been definitively established. Arguments have been made for
several possibilities, and several factors may be operative in any patient:

● Increased responsiveness of the peripheral receptors themselves.

● Increased responsiveness of the baroreceptor region due to comorbidities

such as atherosclerotic vascular disease, nearby neck surgery, or irradiation
that alters the receptor milieu.

● Abnormal proprioception responses in nearby neck muscles that modify the

manner in which central sites interpret baroreceptor afferent signals.

● Increased responsiveness of midbrain reflex sites.

CLINICAL FEATURES

CSH is a clinical observation of heart rate (HR) pauses and drop in systolic blood
pressure (BP) but is not inherently a clinical condition requiring treatment. CSS
reflects the spontaneous clinical manifestation of CSH when changes in HR
and/or BP cause symptoms, most commonly syncope, lightheadedness, or
otherwise unexplained falls in older patients.
Carotid sinus hypersensitivity — CSH, most commonly identified as a pause
duration of >3 seconds or drop in BP >50 mmHg during carotid sinus massage,
may or may not be associated with symptoms [1]. However, as with the debate
over the definition of CSH, there are several reasons these criteria are inadequately
sensitive and specific, most notably:

● Symptoms are unlikely to be induced by a three-second pause alone, as a

pause as long as six to nine seconds may be necessary to overcome residual
neural energy stores.

● If a pause alone is used as a definition, then the vasodilation component of the

reflex is essentially being disregarded (ie, hypotension may occur with marked
bradycardia).

● Both bradycardia and vascular dilation may work synergistically and contribute
to symptomatic hypotension.

One examination of diagnostic criteria suggests that when carotid sinus massage
is used as part of the overall diagnostic evaluation of syncope of unknown cause,
an induced pause or cerebral hypotension duration of >5 seconds is a more
reasonable diagnostic standard in the absence of an alternative cause for
symptoms [3].

Carotid sinus syndrome — CSS may present with a variety of symptoms following

carotid baroreceptor stimulation, but one or more of the following are most
common:

● Lightheadedness/presyncope
● Syncope
● Otherwise unexplained falls in older patients

Risk factors such as older age, male gender, concomitant atherosclerotic disease,
prior neck surgery, or neck irradiation should increase suspicion. CSS is diagnosed
when, by history, spontaneous syncope symptoms can be reasonably attributed to
mechanical manipulation of the carotid sinuses. Unfortunately, obtaining a clear
history of carotid sinus stimulation is challenging and uncommon. Symptoms
including syncope may be reproduced by carotid sinus massage, but while such
demonstration can be of greatest value in establishing CSS as the diagnosis, it is
often not possible. Reproduction of symptoms may be better achieved if carotid
sinus massage is undertaken with the patient in an upright position. The latter is
most safely accomplished with the patient gently secured on a tilt table so the
patient can be prevented from falling. (See 'Diagnostic testing' below.)

When CSS manifests as true syncope, it is commonly termed carotid sinus

syncope, a type of reflex syncope.

DIAGNOSTIC TESTING

An overview of the diagnostic approach to lightheadedness, near-syncope, and

syncope in general is provided elsewhere. (See "Syncope in adults: Clinical
manifestations and initial diagnostic evaluation".)

Apart from careful exclusion of other possible causes of symptoms, the only
relatively specific test for CSH/CSS is carotid sinus massage usually best
performed in combination with upright posture. Both the American and European
syncope guidelines recommend including carotid sinus massage after the initial
evaluation in patients over age 40 with syncope of unknown etiology (but in whom
other findings are suggestive of a reflex mechanism) [1,2].

Carotid sinus massage — CSH can often be demonstrated by careful carotid sinus

massage. Firm massage is applied at the region of the carotid baroreceptors
(approximately over the carotid artery just below the angle of the mandible) (
figure 1) [11].

Contraindications — Carotid sinus massage should be avoided in patients with

prior transient ischemic attack or stroke within the past three months and in
patients with carotid bruits (unless carotid Doppler studies have excluded
significant stenosis) [1,2]. (See "Vagal maneuvers", section on 'Contraindications'.)

Technique — Carotid sinus massage methodology varies among laboratories,

but one recommended method is performed as follows:

● The patient is placed in the supine position with the neck extended (ie, raising
the chin away from the chest) to maximize access to the carotid artery. The
carotid sinus is usually located inferior to the angle of the mandible at the level
of the thyroid cartilage near the arterial impulse (figure 1). If the test is non-
diagnostic in terms of reproducing symptoms, then it should be repeated with
the patient in a more upright posture.

● Pressure is applied to one carotid sinus for 5 to 10 seconds. Although pulsatile

pressure via vigorous circular motion may be more effective, steady pressure
is recommended because it may be more reproducible [1,12]. If the initial
response is nondiagnostic, the procedure should be repeated on the
contralateral side (unless contraindicated) following a one- to two-minute
delay.

● Symptoms associated with CSH are rarely induced unless carotid sinus
massage is carried out with the patient upright. If the response is
nondiagnostic in the supine position, the procedure should be repeated with
the patient seated upright or positioned head-up on a tilt table (but gently
secured so as not to fall).

Combination with tilt table testing — The 2017 ACC/AHA/HRS syncope

guidelines recommend performance of carotid sinus massage with the patient in
both the supine and head-up positions. The diagnostic yield may be increased by
performing the massage during head-up tilt testing as this allows for inducing a
greater degree of hypotension and is therefore more likely to reproduce symptoms
[13,14]. In a report of 1149 patients over 55 years of age presenting with
unexplained syncope, CSH provoked by carotid sinus massage was observed in
223 patients (19 percent); in one-third of these patients, a response to carotid
sinus massage was elicited during tilt table testing after a negative response to
supine massage [14]. (See "Upright tilt table testing in the evaluation of syncope".)

Monitoring — When carotid sinus massage is performed in a medical

environment (eg, hospital, clinic, etc), all patients should have vital signs
monitored before and after the maneuver. Patients with suspected CSH/CSS
should have frequent blood pressure (BP) monitoring (preferably beat-to-beat, not
by sphygmomanometer) along with continuous heart rate (HR) monitoring (single-
lead telemetry is adequate) during the massage. The recordings are best achieved
with a beat-by-beat noninvasive HR/BP monitor system (eg, Finapres).

Test results — Experts disagree on what constitutes a "positive" (ie, abnormal)

response to carotid sinus massage, thereby suggesting CSH (or CSS if
spontaneous symptoms are reproduced). The disagreement mainly focuses on
the length of the HR pause that is considered abnormal. (See 'Definition' above.)

The test is generally considered positive in the following situations:

● Positive for CSH following induction of either a pause >3 seconds (with some
experts preferring >5 seconds) OR a drop of systolic BP >50 mmHg [1-3].

● Positive for CSS if symptoms of lightheadedness or syncope consistent with

the patient's spontaneous complaints are reproduced (ie, so-called "method of
symptoms").

The response to carotid sinus massage is generally classified as cardioinhibitory,

vasodepressor, or mixed. In most cases, the response is "mixed," indicating that
symptoms in patients with CSS are a combination of HR slowing and vasodilation.
The combination is a typical feature of all reflex faints such as vasovagal syncope.
A positive (abnormal) response to carotid sinus massage may be considered
diagnostic of the cause of syncope if other competing diagnoses can be
reasonably excluded by history and/or laboratory testing. (See 'Diagnosis' below.)
CSH is more common in older adult patient populations. Carotid sinus massage
may unmask CSH in older adult patients, but this should not automatically be
deemed a diagnostic finding in patients with lightheadedness, syncope, or falls [8].
In an unselected sample of 272 older adult patients (mean age 71 years) from a
community practice who underwent carotid sinus massage in both the supine and
upright positions, CSH was present in 39 percent overall and in 35 percent of
individuals with no prior falls, syncope, or dizziness [15]. Thus, alternative causes
should be explored before attributing syncope to CSH in older adult patients. Given
the limited sensitivity and specificity of carotid sinus massage for diagnosing CSS,
some have advocated using stricter criteria for identification of CSH [3].

DIAGNOSIS

CSH is identified based on a heart rate (HR) pause duration of >3 seconds (some
prefer >5 seconds, as discussed above) or drop in blood pressure (BP) >50 mmHg
during carotid sinus massage.

CSS is diagnosed by the combination of reproducing appropriate spontaneous

symptoms and documented CSH following carotid sinus massage. When CSH is
documented following carotid sinus massage, concurrent symptoms provide the
most convincing evidence for CSS. An asymptomatic "positive" response for CSH
is less sensitive and less specific than reproduction of symptoms, particularly if a
full evaluation for other causes of syncope has not yet been performed. (See 'Test
results' above.)

By history, spontaneous syncope symptoms can be reasonably attributed to

mechanical manipulation of the carotid sinuses resulting in CSH. CSS symptoms
are deemed to result from CSH-induced excessive and inappropriate
cardioinhibition (ie, slowing of HR) and/or vasodilation, yielding a drop in BP. Both
cardioinhibition and vasodilation transiently diminish brain perfusion. Elements of
both cardioinhibition and vasodilation (ie, "mixed response") are usually present
and contribute to symptoms.

CSS is one of many potential causes for syncope, near-syncope, or unexplained

fall symptoms. The diagnosis of CSS depends on suspicion after obtaining a very
careful medical history. Rarely is a clear-cut relationship established between neck
movements and symptom episodes. Nonetheless, although it is rarely present, a
history of syncope following accidental manipulation of the carotid sinuses should
be sought. Absence of such a history does not exclude CSS. (See 'Clinical features'
above.)

The finding of CSH in older adult patients should not be construed as diagnostic
for the presenting symptoms (ie, lightheadedness, syncope, falls) unless other
causes of the symptoms have been eliminated or the history clearly relates
symptoms to neck movement or mechanical distortion.

DIFFERENTIAL DIAGNOSIS

In regard to pathophysiology, carotid sinus syncope is similar, in terms of

cardioinhibition and vasodilation components, to other forms of reflex syncope
such as vasovagal syncope. However, precipitating factors for these two types of
reflex syncope differ. Carotid sinus syncope (and CSS in general) is attributed to
mechanical stress on hypersensitive carotid baroreceptors whereas vasovagal
syncope is most often triggered by emotional events, painful stimuli, or prolonged
upright posture. Other reflex faints (eg, defecation syncope, swallow syncope,
trumpet blowers syncope) may also need to be considered depending on the
specific circumstances of the patient presentation. (See 'Clinical features' above.)

A full discussion of the differential diagnosis of syncope in adults is presented

separately. (See "Syncope in adults: Epidemiology, pathogenesis, and etiologies".)
MANAGEMENT

The management of patients with CSH is directed by the presence or absence of

symptoms. Permanent cardiac pacing is the appropriate therapy for many patients
with CSS and an abnormal cardioinhibitory response following cardiac massage.
Vasoconstrictor drugs (eg, midodrine) may also be needed in a minority of cases if
the vasodepressor component of the reflex is particularly powerful in a given
patient. Additional restrictions should be placed on driving until appropriate
treatment has been provided (rules related to driving restriction vary by locale, and
local laws should be consulted). Conversely, patients with isolated CSH who
remain asymptomatic require no specific therapy.

General measures — CSS is a multifaceted syndrome in terms of symptoms as

well as pathophysiology (ie, cardioinhibitory and vasodepressor components). In
addition, symptoms are usually infrequent and sporadic. Consequently, it is
important to consider the risks associated with treating the patient every day for
prevention of infrequent events.

Education is an important treatment strategy. Risks of CSS to the patient and

bystanders should be discussed in detail. Lightheadedness and near-syncope may
not cause frank loss of consciousness but can cause inattention and slow
reaction times during operation of vehicles and machinery. The latter promote the
chances of accidents and falls with potential for major injury. Syncope may occur
with a similar potential for hazard to the patient and others if the patient loses
control of a vehicle or other machine or simply falls in a crowded environment.
(See 'Driving restrictions' below.)

Consequently, general treatment measures include education regarding the nature,

risks, and prognosis of the condition [1]. The patient should be advised to avoid
accidental mechanical manipulation of the carotid sinuses such as might occur if
they receive medical or chiropractic treatments to the neck area or wear tight
collars.

Relatively little is known of the optimal treatment of patients with a predominant

vasodilatory response to carotid sinus massage, as these cases seem to be rare
(or at least rarely recognized) and therefore difficult to study. As an initial step,
drugs, such as vasodilators or diuretics, that may exacerbate the condition should
be reduced or discontinued, if feasible. Although some therapies for vasovagal
syncope (such as salt loading and vasoconstrictors) may be expected to be
helpful, such treatments may cause supine hypertension and are usually
undesirable in the older patient population with CSS [1]. Vasoconstrictive drugs
such as midodrine or droxidopa are theoretically appealing, but there are no data
to support their use [2]. Additionally, vasoconstrictive drugs must be used
cautiously to minimize the risk of hypertension. In individuals with CSS and
essential hypertension (a common combination), it is necessary to use
vasoconstrictors during waking hours and short-acting antihypertensives at
bedtime to diminish supine hypertension.

Permanent pacing for symptomatic patients — For patients with CSS (ie, a history
of suspected reflex syncope and a positive cardioinhibitory response following
carotid sinus massage), we suggest implanting a permanent cardiac pacemaker in
the following situations [2]:

● Patients with recurrent syncope believed to be due to CSS with a

cardioinhibitory or "mixed" response to carotid sinus massage resulting in
asystole for more than three to five seconds. However, a predominant
vasodilatory response (drop in systolic blood pressure >50 mmHg) without
associated cardioinhibition may be associated with decreased pacemaker
effectiveness (ie, patients may continue to experience symptoms despite
pacing due to the vasodepressor component causing hypotension) [16].
 ● Patients with recurrent syncope/falls of unexplained origin and a
cardioinhibitory response to carotid sinus massage resulting in asystole for
more than three to five seconds. Permanent pacing is NOT indicated for a
cardioinhibitory response to carotid sinus stimulation without symptoms or
with vague symptoms.

When a pacemaker is placed, dual-chamber pacing is favored. Single-chamber AAI

pacing is NOT recommended for patients with CSS, as transient AV block may
occur during an episode and eliminate any potential pacing benefit. This approach
is in general agreement with published society guidelines [1].

A positive cardioinhibitory response (asystole >3 to 5 seconds) during carotid

sinus massage is thought to be predictive of an asystolic mechanism of
spontaneous syncope, but the evidence is based on small studies [17,18]. As an
example, in a study of 18 patients with recurrent syncope and cardioinhibitory
response to carotid sinus massage and 36 patients with recurrent syncope and
negative response to carotid sinus massage, insertable cardiac monitors (also
sometimes referred to as implantable cardiac monitors or implantable loop
recorders) identified the following [18]:

● Asystole with syncope in 16 of 18 (89 percent) patients with a positive

cardioinhibitory response to carotid sinus massage

● Asystolic with syncope in 18 of 36 (50 percent) patients with a negative

cardioinhibitory response to carotid sinus massage

In CSS, virtually all studies seem to favor the value of pacing despite the fact that
both cardioinhibitory and vasodepressor mechanisms may be operating. This
latter observation differs from other reflex conditions such as the vasovagal faint
in which a predominant vasodepressor component may undermine the value of
pacing therapy. Why these two forms of reflex symptoms are so different is
unknown.
Two small randomized trials found that pacing reduced the rate of syncope
recurrence in patients with CSS [19,20]. Dual-chamber pacing is beneficial in
patients with CSH who have a cardioinhibitory response, but not in those with a
pure vasodilatory response.

Pacing may prevent nonmechanical falls as well as syncope. This was illustrated
in the SAFE PACE trial, in which 175 patients seen in an emergency facility
because of a nonmechanical fall without loss of consciousness were randomly
assigned to a dual-chamber pacemaker or no therapy [21], but not confirmed in
SAFE PACE 2 [22].

In a study of 21 patients with CSS and syncope or near-syncope, patients were

randomized to VVI, DDDR, or DDDR with a sudden bradycardia response in a
double-blinded sequential crossover basis with six months in each mode [23].
There were 29 syncopal and 258 presyncopal events among 21 patients.
Following pacing, syncopal events reduced to two in two patients (p<0.001) and
17 presyncopal events (p<0.001) in 12 patients, and these events were not related
to the three pacing methods. While these data do not support one specific mode
of pacing, some patients do respond to AV sequential pacing better
hemodynamically, and if this is known a priori, we suggest a dual-chamber
pacemaker be implanted from the start. Failure of pacing most likely would be due
to the patient having a prominent vasodepressor component of the CSS
reflex, similar to what may happen in patients with vasovagal syncope.

Asymptomatic patients — No specific therapy is required for patients with

documented CSH without associated symptoms. However, patients with a
documented abnormal response to carotid sinus massage should be counselled
to avoid movements or positions that may accidentally stimulate the carotid
baroreceptors.

Driving restrictions — In general, we agree with the 2017 ACC/AHA/HRS syncope

guidelines regarding driving restriction recommendations for patients with CSS (
table 1) [1]. Nonetheless, it is prudent to consult local laws and regulations.

● Patients with CSH alone but without symptoms – No restriction.

● Patients with untreated CSS (ie, known or suspected [by history] relation of
symptoms to CSH in the absence of alternative cause) – Not fit to drive.

● Patients with CSS as above but treated with a permanent pacemaker to

overcome a predominant cardioinhibitory component – May drive after one
week of observation to ensure stable pacing system is in place.

● Patients with CSS in whom the vasodepressor component is dominant

(relatively rare), but who are treated to diminish vasodilation – May drive after
a reasonable observation period to demonstrate treatment effectiveness.

Recommendations for commercial drivers are linked to local and/or federal

government department of transportation or comparable regulatory body
regulations [24]. Generally, a symptom-free period of six months is required, but
regulations differ geographically. Practitioners must be aware of local laws and
regulations in their region, which may differ from professional society guidelines.
(See "Syncope in adults: Management", section on 'Driving restrictions'.)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain
language, at the 5th to 6th grade reading level, and they answer the four or five key
questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also locate
patient education articles on a variety of subjects by searching on "patient info"
and the keyword(s) of interest.)

● Basics topics (see "Patient education: Vagal maneuvers and their responses
(The Basics)")

SUMMARY AND RECOMMENDATIONS

● Carotid sinus syndrome (CSS) results from carotid sinus hypersensitivity
(CSH) and is a cause of fainting and collapse in some patients. Its incidence
increases with age. CSH itself is not an indication for treatment. Treatment is
only warranted if CSH is deemed responsible for symptoms of syncope,
lightheadedness, or unexplained falls, in which case the condition is termed
carotid sinus syndrome. (See 'Definition' above and 'Prevalence' above.)

● Carotid sinus massage is recommended as part of the diagnostic workup for

patients over age 40 with syncope of unknown etiology without
contraindication to carotid sinus massage. However, false positive results are
common in older adults, so other potential causes of syncope or collapse
should be excluded. (See 'Diagnostic testing' above.)

● General treatment measures include education regarding the risks associated

with CSS and its treatment. (See 'General measures' above.)

● Dual-chamber pacing is often helpful in patients with CSS who are found to
have a slow heart rate (HR) or prolonged pause in their heart rhythm as a
cause of their symptoms. Since the slow HR is only part of the problem, pacing
may not be a perfect solution in all individuals. However, it is valuable in most
CSS patients. Medications may need to be added to diminish the vasodilatory
component for some other patients.
 • Patients with recurrent syncope in the setting of a history of spontaneous
carotid sinus stimulation, who also have ventricular asystole of more than
three to five seconds in response to carotid sinus massage, are considered
to have been definitively diagnosed with carotid sinus syncope. We
recommend that such patients be treated with a permanent pacemaker
(Grade 2C). (See 'Management' above.)

• Patients with recurrent syncope or collapse of unexplained origin and a

hypersensitive cardioinhibitory response of longer than three to five
seconds may also have CSS. In the absence of a plausible alternate cause
after detailed evaluation, we suggest placement of a pacemaker in such
patients (Grade 2C).

ACKNOWLEDGMENT

The editorial staff at UpToDate would like to acknowledge Brian Olshansky, MD,
who contributed to an earlier version of this topic review.

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