Effect of Carotid Sinus Massage and Tilt-Table Testing
in a Normal, Healthy Older Population (The Healthy
Ageing Study)
Paul G. McGlinchey,
MRCP
, Lynne Armstrong,
MD
, Mark S. Spence,
MRCP
,
Michael J. D. Roberts,
MD
, and Pascal P. McKeown,
MD
E
xperience from clinics dedicated to treating syn-
cope in older people suggests that carotid sinus
syndrome and vasodepressor vasovagal syncope ac-
count for Ͼ50% of cases of syncope in this group.
1,2
Tilt-table techniques combined with carotid sinus
massage (CSM) are required to establish these diag-
noses. In light of the difficulty in establishing an
accurate diagnosis of syncope in older people, there
has been increasing enthusiasm for the use of CSM
and tilt testing. The response of “healthy” older sub-
jects to these maneuvers has not been clearly delin-
eated. We have investigated normal cardiovascular
responses, in particular the spectrum of responses to
CSM and tilt testing, in a carefully defined group of
healthy, older subjects.
•••
Ethical approval was obtained from the Research
Ethics Committee of The Queen’s University of Bel-
fast, Northern Ireland. Subjects aged 60 to 80 years
were recruited from a register of randomly selected
controls in the Department of Epidemiology & Public
Health, The Queen’s University of Belfast, and other
local databases.
We sought to identify normal, healthy persons for
further investigation. Volunteers were excluded if
they provided a history of syncope, unexplained falls,
cardiovascular or cerebrovascular disease, or diabetes
mellitus. Other exclusion criteria included presence of
a carotid bruit, abnormal resting 12-lead electrocar-
diogram, serum hemoglobin concentration Ͻ11 g/dl,
random blood glucose concentration Ն11.1 mmol/L,
serum creatinine concentration Ͼ150
mol/L, current
use of medications known to influence cardiovascular
responses to CSM or tilt-table testing, and orthostatic
hypotension (defined as a decrease in systolic blood
pressure Ն20 mm Hg, decrease in diastolic blood
pressure Ն10 mm Hg, or decrease in systolic blood
pressure to Ͻ90 mm Hg). Unsuitable volunteers were
excluded at this stage. All subjects gave written in-
formed consent for enrollment in the study.
Echocardiography, carotid ultrasonography, and
ambulatory electrocardiographic assessment were per-
formed on subjects meeting the entry criteria. Two-
dimensional, M-mode, and Doppler echocardiography
was performed to exclude structural heart disease, left
ventricular dysfunction, and presence of valvular dis-
ease (Acuson-Sequoia, Mountain View, California; or
ATL Ultramark 9, Bothell, Washington). Carotid ultra-
sonography with Doppler interrogation was performed to
exclude significant occult carotid atherosclerosis (ATL
HDL 5000). Ambulatory electrocardiography was per-
formed for 48 hours using a 2-channel Holter monitor
and the recording analyzed for the presence of dysrhyth-
mia (Reynolds Pathfinder 7000, Hertford, Herts, United
Kingdom).
The final component of the study was assessment
of the cardiovascular response to CSM and tilt-table
testing. These tests were performed between 9
A
.
M
.
and noon in a quiet, comfortably cool, darkened room,
normally used for tilt-table testing, with the volunteers
having fasted overnight. The subjects were asked to
lie supine on a tilt table with their feet apposed to the
foot plate and with body straps gently applied. A
forearm vein was cannulated and a slow-running sa-
line infusion administered. Continuous noninvasive
beat-to-beat finger arterial pressure monitoring was
performed throughout the procedure using the Portap-
res model-2 device/software (Biomedical Instrumen-
tation, Amsterdam, The Netherlands). Continuous sur-
face electrocardiographic recordings were performed
throughout the procedure (Siemens SC7000 multipa-
rameter monitor, Erlangen, Germany).
CSM was performed by firmly massaging the ca-
rotid artery for 5 seconds at the anterior margin of the
sternomastoid muscle at the level of the cricoid carti-
lage. This was performed first on the right side with
the patient supine and repeated on the left side after 1
minute. Positive responses were defined as: a decrease
in systolic blood pressure of Ն50 mm Hg (vasode-
pressor response), a ventricular pause of Ͼ3 seconds
(cardioinhibitory response), or a combination of a
Ͼ3-second pause with a decrease in systolic blood
pressure of Ն50 mm Hg on rhythm resumption
(mixed response). CSM was then repeated with the
patient tilted at 70°.
If the CSM demonstrated a normal response, the
subject remained in this position for commencement
of tilt testing. The test was timed as beginning at 1
minute after CSM had been completed. If an abnormal
response occurred during CSM, the subject was re-
From the Regional Medical Cardiology Centre, Royal Victoria Hospi-
tal, Belfast, Northern Ireland; Craigavon Area Hospital, Craigavon,
Co. Armagh, Northern Ireland; and Department of Medicine, The
Queen’s University of Belfast, Institute of Clinical Science, Belfast,
Northern Ireland, United Kingdom. This work was supported by a
research grant from the Northern Ireland Chest Heart and Stroke
Association, Belfast, Northern Ireland, United Kingdom. Dr. McKe-
own’s research is supported in part by the Heart Trust Fund (Royal
Victoria Hospital), Comber, County Down, Northern Ireland, United
Kingdom. Dr. McKeown’s address is: Department of Medicine, The
Queen’s University of Belfast, Institute of Clinical Science, Grosvenor
Road, Belfast BT12 6BJ, Northern Ireland, United Kingdom. E-mail:
p.p.mckeown@qub.ac.uk. Manuscript received March 5, 2002; re-
vised manuscript received and accepted June 21, 2002.
1015
©2002 by Excerpta Medica, Inc. All rights reserved. 0002-9149/02/$–see front matter
The American Journal of Cardiology Vol. 90 November 1, 2002 PII S0002-9149(02)02691-7