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

Abstract

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.

Keywords: Carotid sinus massage; Haemodynamic monitoring; Syncope; Tilt table testing; Video recording.

Graphical Abstract

Figure 1

Schematic drawing of the baroreceptor afferent and autonomic efferent pathways of the baroreflex arc. The afferent signals are transferred to the cardiovascular (CV) centre in medulla oblongata by the glossopharyngeal nerve (IX). When activated, the centre acts through efferents on effector organs via the vagus nerve (X) to the heart, causing bradycardia or asystole, and via sympathetic ganglia, leading to profound vasodilation and hypotension. CSM, carotid sinus massage.

Figure 2

Carotid sinus massage performed on the right side in supine position in 50-year-old woman with recurrent syncopal attacks occurring in different body positions, including lying in the bed. A profound cardioinhibitory response with sinus arrest of 10 s, syncope, and total reproduction of spontaneous attacks. Please note that the slight deceleration of heart rate in the two beats preceding the marker (‘START’) was due to a gentle pressure to the neck when looking for the maximal pulsation, like we describe in step 3 of the Six-Step-Method. The patient was effectively treated with pacemaker and without recurrences over a period of five years. CSM, carotid sinus massage.

Figure 3

The sequence of carotid sinus massages.

Figure 4

The Six-Step-Method for carotid sinus massage. Carotid sinus massage should be performed in supine position on both left and right sides followed by both the left and right sides in upright position. For this, a tilt table is required to perform CSM in standing position (see also explanatory video as Supplementary file). This figure is also available as a poster provided as Supplementary material.