title: Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes.
abstract: OBJECTIVE
  Opinions differ regarding the effectiveness of cardiac pacing in patients affected by reflex syncope. We assessed a standardized guideline-based algorithm in different forms of reflex syncope.
  
  
  RESULTS
  In this prospective, multi-centre, observational study, patients aged >40 years, affected by severe unpredictable recurrent reflex syncopes, underwent carotid sinus massage (CSM), followed by tilt testing (TT) if CSM was negative, followed by implantation of an implantable loop recorder (ILR) if TT was negative. Those who had an asystolic response to one of these tests received a dual-chamber pacemaker.
  
  
  METHODS
  253 patients, mean age 70 ± 12 years, median 4 (3-6) syncopes, 89% without or with short prodromes. Of these patients, 120 (47%) received a pacemaker and 106 were followed up for a mean of 13 ± 7 months: syncope recurred in 10 (9%). The recurrence rate was similar in 61 CSM+ (11%), 30 TT+ (7%), and 15 ILR+ (7%) patients. The actuarial total syncope recurrence rate was 9% (95% confidence interval (CI), 6-12) at 1 year and 15% (95% CI, 10-20) at 2 years and was significantly lower than that observed in the group of 124 patients with non-diagnostic tests who had received an ILR: i.e. 22% (95% CI, 18-26) at 1 year and 37% (95% CI, 30-43) at 2 years (P = 0.004).
  
  
  CONCLUSIONS
  About half of older patients with severe recurrent syncopes without prodromes have an asystolic reflex for which cardiac pacing goes along with a low recurrence rate. The study supports the clinical utility of the algorithm for the selection of candidates to cardiac pacing in everyday clinical practice.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov. Unique identifier: NCT01509534.
authors.affiliation: Arrhythmology Centre, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy mbrignole@asl4.liguria.it.
authors.forename: Michele
authors.initials: M
authors.lastname: Brignole
authors.affiliation: Ospedale 'GB Grassi', Ostia, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Ammirati
authors.affiliation: Ospedale Pugliese Ciaccio, Catanzaro, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Arabia
authors.affiliation: Arcispedale S. Maria Nuova, Reggio Emilia, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Quartieri
authors.affiliation: Ospedale Generale Regionale, Bolzano, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Tomaino
authors.affiliation: Ospedale Careggi, Firenze, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ungar
authors.affiliation: Ospedale Niguarda Ca' Granda, Milano, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Lunati
authors.affiliation: Ospedale SS. Annunziata, Taranto, Italy.
authors.forename: Vitantonio
authors.initials: V
authors.lastname: Russo
authors.affiliation: Ospedale S. Giuseppe, Empoli, Italy.
authors.forename: Attilio
authors.initials: A
authors.lastname: Del Rosso
authors.affiliation: Ospedale Villa Scassi, Genova, Italy.
authors.forename: Germano
authors.initials: G
authors.lastname: Gaggioli
mesh_terms: D000368:Aged; D000465:Algorithms; D002304:Cardiac Pacing, Artificial; D015716:Electrocardiography, Ambulatory / Q000295:instrumentation; D005260:Female; D006801:Humans; D008297:Male; D008405:Massage / Q000379:methods; D011446:Prospective Studies; D055502:Secondary Prevention; D013575:Syncope / Q000209:etiology / Q000517:prevention & control / Q000628:therapy*; D018667:Tilt-Table Test; D016896:Treatment Outcome
keywords: Cardiac pacing; Carotid sinus massage; Implantable loop recorder; Syncope; Tilt table test