Presence of a carotid bruit in adults with unexplained or recurrent falls: implications for carotid sinus massage.

BACKGROUND Carotid sinus hypersensitivity is a common cardiovascular cause of unexplained or recurrent falls in older adults. Effective treatment is available once carotid sinus hypersensitivity is identified. Carotid sinus massage is the only practical method for achieving a diagnosis. Carotid sinus massage is contraindicated if a carotid bruit is present. OBJECTIVE To determine the prevalence of carotid sinus hypersensitivity in adults presenting with unexplained or recurrent falls and a carotid bruit. DESIGN Prospective consecutive cohort study. SETTING Accident and Emergency department and regional syncope and falls facility. SUBJECTS Accident and Emergency patients aged 50 years or over with unexplained or recurrent falls and a carotid bruit. INTERVENTION 1) Carotid doppler ultrasound to identify significant stenosis (> or = 50%). 2) Carotid sinus massage (with electrocardiographic and phasic blood pressure monitoring) was performed supine and possibly upright. METHODS Consecutive adults with unexplained or recurrent falls were screened for carotid bruits. Those with a carotid bruit were referred for carotid Doppler ultrasound and stratified for further investigation depending on presence and degree of underlying carotid artery stenosis. Carotid sinus massage was performed at least supine in those with up to moderate stenosis (50-69%) in either internal or common carotid artery. MAIN OUTCOME MEASURE Diagnosis of carotid sinus hypersensitivity. RESULTS We identified 1682 subjects with unexplained or recurrent falls of whom 179 (11%) had a carotid bruit, 167 underwent ultrasound, 31% had a stenosis > or = 50% (20% > or = 70%) in either internal or common carotid artery. A bruit was associated with significant ipsilateral stenosis in 25% and contralateral silent stenosis in a further 5%. Carotid sinus massage was performed in 121 subjects who were suitable (15 with moderate carotid artery stenosis). Carotid sinus hypersensitivity was found in 41 (34%) subjects (4 with moderate stenosis). No serious complications occurred following carotid sinus massage. CONCLUSIONS Carotid sinus hypersensitivity is a possible attributable cause of symptoms in a third of subjects with unexplained or recurrent falls and carotid bruits. Only a small number have severe carotid artery stenosis. Ultrasound will identify high-risk subjects and facilitate accurate diagnosis with carotid sinus massage in the majority.