Hostname: page-component-586b7cd67f-2plfb Total loading time: 0 Render date: 2024-11-23T03:09:32.232Z Has data issue: false hasContentIssue false
  • English
  • Français

Update on syncope in the older person – a clinical review

Published online by Cambridge University Press:  20 December 2012

Riaz Mappilakkandy  and
Ian Edwards
Riaz Mappilakkandy*
Affiliation:
Department of Geriatric Medicine, Northampton General Hospital, Northampton, UK
Ian Edwards
Affiliation:
Department of Geriatric Medicine, Northampton General Hospital, Northampton, UK
*
Address for correspondence: Dr Riaz A. Mappilakkandy, Consultant Physician, Department of Geriatric Medicine, Northampton General Hospital, Cliftonville, Northampton NN1 5BD. Email: [email protected]
Get access Rights & Permissions [Opens in a new window]

Summary

Syncope is a common cause of presentation to the emergency department in the older population, who are at increased risk of syncope resulting in serious injury in the form of fractures, adverse cardiac outcomes and death, lack of confidence and mental health issues. Older patients can present diagnostic challenges due to multiple co-morbidities, polypharmacy and the problem of amnesia associated with transient loss of consciousness. The underlying cause of their syncope can be established through a structured approach, and targeted patient selection can limit inappropriate investigations in syncope assessment units and ensure appropriate treatments are instituted. A previous review article in this journal, by Nath and Kenny in 2005, examined the evidence surrounding various aspects of syncope, including prevalence, cause, risks, investigations and treatment. This review updates the evidence and guidelines on the aetiology, investigation and treatments of syncope in the older person, with emphasis on recent advances.

Keywords

syncopeelderlycarotid sinus hypersensitivityvasovagal syncopeorthostatic hypotension
Type
Clinical geriatrics
Information
Reviews in Clinical Gerontology , Volume 23 , Issue 1 , February 2013 , pp. 15 - 31
Copyright
Copyright © Cambridge University Press 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1Moya, A, Sutton, R, Ammirati, F, Blanc, JJ, Brignole, M, Dahm, JBet al.Guidelines for the diagnosis and management of syncope (version 2009): the task force for the diagnosis and management of syncope of the European Society of Cardiology (ESC). Eur Heart J 2009; 30: 2631–71.Google Scholar
2Thijs, RD, Benditt, DG, Mathias, Cet al.Unconscious confusion. A literature search for definitions of syncope and related disorders. Clin Auton Res 2005; 15: 35–39.CrossRefGoogle ScholarPubMed
3Galizia, G; Abete, P; Mussi, Cet al.Role of early symptoms in assessment of syncope in elderly people: results from the Italian group for the study of syncope in the elderly. J Am Geriatrics Soc 2009; 57:18–23.CrossRefGoogle Scholar
4Quinn, J, McDermott, D, Stiell, I, Kohn, M, Wells, G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med 47 2006; 5: 448–54.CrossRefGoogle ScholarPubMed
5Thiruganasambandamoorthy, V, Hess, EP, Turko, E, Tran, ML, Wells, GA, Stiell, IG. Defining abnormal electrocardiography in adult emergency department syncope patients: the Ottawa Electrocardiographic Criteria. Canadian J Emergency Med 2012; 14: 248–58.Google Scholar
6Mendu, ML, McAvay, G, Lampert, R, Stoehr, J, Tinetti, ME. Yields of diagnostic tests in evaluating syncope in older patients. Arch Intern Med 2009; 169: 1299–305.Google ScholarPubMed
7Parry, SW, Tan, MP. An approach to the evaluation and management of syncope in adults. BMJ 2010; 340: c880.CrossRefGoogle Scholar
8Sun, BC, Hoffman, JR, Mangione, CM, Mower, WR. Older age predicts short-term, serious events after syncope. J Am Geriatrics Soc 2007; 55: 907–12.CrossRefGoogle ScholarPubMed
9Sun, BC, Derose, SF, Liang, LJet al.Predictors of 30-day serious events in older patients with syncope. Annals Emergency Med 2009; 54: 769–78.CrossRefGoogle ScholarPubMed
10Sun, BC, Emond, JA, Camargo, CA Jr. Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol 2005; 95: 668–71.CrossRefGoogle ScholarPubMed
11O'Dwyer, C, Bennett, K, Langan, Y, Fan, CW, Kenny, R. Amnesia for loss of consciousness is common in vasovagal syncope. Europace 2011; 13: 1040–45.CrossRefGoogle ScholarPubMed
12Lempert, T, Bauer, M, Schmidt, D. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia. Ann Neurol 1994; 36: 233–37.CrossRefGoogle ScholarPubMed
13Nath, S, Kenny, R. Syncope in the older person: a review. Rev Clinical Gerontol 2005; 15: 219–35.CrossRefGoogle Scholar
14Lipzitz, L, Wei, J, Rowe, J. Syncope in an elderly, institutionalised population: prevalence, incidence, and associated risk. QJM: Int J Med 55: 45–54.Google Scholar
15Chen, L, Shen, W, Mahoney, Det al.Prevalence of syncope in a population aged more than 45 years. Am J Med 2006; 119: 1088.e1–7.CrossRefGoogle Scholar
16Soteriades, ES, Evans, JC, Larson, MG, Chen, MH, Chen, L, Benjamin, EJ, Levy, D. Incidence and prognosis of syncope. N Engl J Med 2002; 347: 878–85.CrossRefGoogle ScholarPubMed
17Hainsworth, R.Pathophysiology of syncope. Clinical Autonomic Res 14, suppl 1, i18–24, doi: 10.1007/s10286-004-1004-2.CrossRefGoogle Scholar
18Deharo, JC, Mechulan, A, Giorgi, R, Franceschi, F, Prevot, S, Peyrouse, Eet al.Adenosine plasma level and A2A adenosine receptor expression: correlation with laboratory tests in patients with neurally mediated syncope. Heart 2012; 98: 855–59.CrossRefGoogle ScholarPubMed
19Mitro, P, Kirsch, P, Valocik, G, Murin, P. A prospective study of the standardised diagnostic evaluation of syncope. Europace 2011; 13: 566–71.CrossRefGoogle ScholarPubMed
20Tan, P, Newton, J, Chadwick, T, Parry, S. The relationship between carotid sinus hypersensitivity, orthostatic hypotension and vasovagal syncope: a case control study. Europace 2008; 10: 1400–5.CrossRefGoogle ScholarPubMed
21Miller, VM, Kenny, RAet al.Medullary autonomic pathology in carotid sinus hypersensitivity. Neuropathol Appl Neurobiol 2008; 34: 403–11.CrossRefGoogle ScholarPubMed
22McIntosh, SJ, Lawson, J, Kenny, RA. Clinical characteristics of vasodepressor, cardioinhibitory, and mixed carotid sinus syndrome in the elderly. Am J Med 1993; 95: 203–8.CrossRefGoogle ScholarPubMed
23Ballard, C, Shaw, F, McKeith, I, Kenny, R. High prevalence of neurovascular instability in neurodegenerative dementias. Neurology 1998; 51: 1760–62.CrossRefGoogle ScholarPubMed
24Brignole, M, Menozzi, C, Del Rosso, Aet al.New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification. Europace 2000; 2: 66–76.CrossRefGoogle ScholarPubMed
25Duncan, GW, Tan, MPet al.Vasovagal syncope in the older person: differences in presentation between older and younger patients. Age Ageing 2010; 39: 465–70.CrossRefGoogle ScholarPubMed
26Gracie, J, Newton, J, Norton, M, Baker, C, Freeston, M. The role of psychological factors in response to treatment in neurocardiogenic (vasovagal) syncope. Europace 2006; 8: 636–43.CrossRefGoogle ScholarPubMed
27Tinetti, ME, Mendes de Leon, CF, Doucette, JT, Baker, DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol 1994; 49: M140–47.CrossRefGoogle ScholarPubMed
28Gupta, V, Lipsitz, LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med 2007; 120: 841–47.CrossRefGoogle ScholarPubMed
29Gribben, B, Pickering, T, Sleight, P, Peto, R. Effect of age and blood pressure on baroreflex sensitivity in man. Clin Geriatric Med 1985; 1: 637–48.Google Scholar
30Immink, R, van der Born, B, van Montrans, G. Impaired autoregulation in patients with malignant hypertension. Circulation 2004; 110: 2241–45.CrossRefGoogle ScholarPubMed
31Baliga, R, Prabhu, G. Orthostatic hypotension in healthy elderly: is it a myth? North Am J Med Sci 2010; 2: 416–18.CrossRefGoogle ScholarPubMed
32Hiitola, P, Enlund, Het al.Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older. J Hum Hypertens 2009; 23: 33–39.CrossRefGoogle ScholarPubMed
33Fedorowski, A, Hedblad, B, Melander, O. Early postural blood pressure response and cause specific mortality among middle-aged adults. Eur J Epidemiol 2011; 26: 537–46.CrossRefGoogle ScholarPubMed
34Mussi, C, Ungar, A, Salvioli, G, Menozzi, C, Bartoletti, A, Giada, F, Lagi, Aet al.Orthostatic hypotension as a cause for syncope in patients older than 65 admitted to emergency departments for transient loss of consciousness. J Gerontol A Biol Sci Med Sci 2009; 64: 801–6.CrossRefGoogle ScholarPubMed
35Bowker, L, Price, J, Smith, S. Oxford Handbook of Geriatric Medicine, 2nd edn. Oxford University Press, Oxford, UK; 2012; p. 102.Google Scholar
36Nevitt, MC, Cummings, SR, Kidd, S. Risk factors for recurrent non syncopal falls – a prospective study. JAMA 1989; 261: 2663–67.CrossRefGoogle Scholar
37Shaw, FE, Kenny, RA. Overlap between syncope and falls in the elderly. Postgrad Med J 1997; 83: 700–8.Google Scholar
38Alboni, P. Clinical history: the cornerstone for defining the cause of syncope. G Ital Cardiol 2012; 13: 563–70.Google ScholarPubMed
39Brignole, M. Distinguishing syncopal from non-syncopal causes of fall in older people. Age Aging 2006; 35 suppl 2: ii46–50.CrossRefGoogle ScholarPubMed
40Bien, B, Wilmanska, J, Janczak, W, Wojskowicz, A, Kasiukiewicz, A, Klimiuk, Ket al.Syncope and near syncope as a multifactoral problem in geriatric patients: systemic hypotension is an underrated predictor for syncope exclusively. Adv Med Sci 2011; 56: 352–60.CrossRefGoogle Scholar
41Bhat, PK, Watanabe, K, Rao, DB, Luisada, AA. Conduction defects in the aging heart. J Am Geriatr Soc 1974; 22: 517–20.CrossRefGoogle ScholarPubMed
42Arthur, W, Kaye, GC. The pathophysiology of common causes of syncope. Postgrad Med J 2000; 76: 750–53.CrossRefGoogle ScholarPubMed
43Braunwald, R. Aortic stenosis. Circulation 1968; 36: 381–86.Google Scholar
44Emedicine: Aortic Stenosis. http://emedicine.medscape.com/article/150638.Google Scholar
45Bhattacharyya, S, Hayward, C, Pepper, J, Senior, R. Risk stratification in asymptomatic severe aortic stenosis: a critical appraisal. Eur Heart J 2012; doi:10.1093/eurheartj/ehs190.CrossRefGoogle ScholarPubMed
46Miniati, M, Cenci, C, Monti, S, Poli, D. Clinical presentation of acute pulmonary embolism: survey of 800 cases. PLoS ONE 2012; 7: e30891. doi:10.1371/journal.pone.0030891.CrossRefGoogle ScholarPubMed
47Zhan, S, Hong, S, Shan-Shan, L, Chen-Ling, Y, Lai, W, Dong-Wei, Set al.Misdiagnosis of aortic dissection: experience of 361 patients. J Clin Hypertens 2012; 14: 256–60.CrossRefGoogle ScholarPubMed
48Del Rosso, A, Alboni, P, Brignole, M, Menozzi, C, Raviele, A. Relation of clinical presentation of syncope to the age of patients. Am J Cardiol 2005; 96: 1431–35.CrossRefGoogle Scholar
49Galizia, G, Abete, P, Mussi, C, Noro, G, Morrione, A, Langellotto, Aet al.A role of early symptoms in assessment of syncope in elderly people: results from the Italian group for the study of syncope in the elderly. J Am Geriatrics Soc 2009; 57: 18–23.CrossRefGoogle Scholar
50Sun, BC, Hoffman, JR, Mangione, CM, Mower, WR. Older age predicts short-term, serious events after syncope. J Am Geriatrics Soc 2007; 55: 907–12.CrossRefGoogle ScholarPubMed
51Duncan, GW, Tan, MP, Newton, JL, Reeve, P, Parry, SW. Vasovagal syncope in the older person: differences in presentation between older and younger patients. Age Ageing 2010; 39: 465–70.CrossRefGoogle ScholarPubMed
52Croci, F, Brignole, M, Alboni, P, Menozzi, C, Raviele, A, Del Rosso, Aet al.The application of a standardized strategy of evaluation in patients with syncope referred to three Syncope Units. Europace 2002; 4: 351–56.CrossRefGoogle ScholarPubMed
53Mendu, ML, McAvay, G, Lampert, R, Stoehr, J, Tinetti, ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med 2009; 169: 1299–305.Google ScholarPubMed
54Ungar, A, Mussi, C, Del Rosso, A, Noro, G, Abete, P, Ghirelli, Let al.for the Italian Group for the Study of Syncope in the Elderly. Diagnosis and characteristics of syncope in older patients referred to geriatric departments. J Am Geriatrics Soc 2006; 54: 1531–36.CrossRefGoogle Scholar
55Galizia, G, Abete, P, Mussi, C, Noro, G, Morrione, A, Langellotto, Aet al.Role of early symptoms in assessment of syncope in elderly people: results from the Italian group for the study of syncope in the elderly. J Am Geriatrics Soc 2009; 57: 18–23.CrossRefGoogle Scholar
56Mitro, P, Kirsch, P, Valočik, G, Murín, P. A prospective study of the standardized diagnostic evaluation of syncope. EP Europace 2010; 13: 566–71.CrossRefGoogle Scholar
57Soteriades, ES, Evans, JC, Larson, MG, Chen, MH, Chen, L, Benjamin, EJ, Levy, D. Incidence and prognosis of syncope. N Engl J Med 2002; 347: 878–85.CrossRefGoogle ScholarPubMed
58Farwell, DJ, Sulke, AN. Does the use of a syncope diagnostic protocol improve the investigation and management of syncope? Heart 2004; 90: 52–58.CrossRefGoogle ScholarPubMed
59Gula, LJ, Krahn, AD, Massel, D, Skanes, A, Yee, R, Klein, GJ. External loop recorders: determinants of diagnostic yield in patients with syncope. Am Heart J 2004; 147: 644–48.CrossRefGoogle ScholarPubMed
60Sivakumaran, S, Krahn, AD, Klein, GJ, Finan, J, Yee, R, Renner, S, Skanes, AC. A prospective randomized comparison of loop recorders versus Holter monitors in patients with syncope or presyncope. Am J Med 2003; 115: 1–5.CrossRefGoogle ScholarPubMed
61Humm, AM, Mathias, CJ. Abnormal cardiovascular responses to carotid sinus massage also occur in vasovagal syncope – implications for diagnosis and treatment. Eur J Neurol 2010; 17: 1061–67.CrossRefGoogle ScholarPubMed
62Milton, JC, Lee, TC, Jackson, SHDeterminants of a positive response to carotid sinus massage and head-up tilt. Eur J Internal Med 2009; 20: 709–11.CrossRefGoogle ScholarPubMed
63Kenny, RA, Ingram, A, Bayliss, J, Sutton, R. Head-up tilt: a useful test for investigating unexplained syncope. Lancet 1986; 1: 1352–55.CrossRefGoogle Scholar
64Vetta, F, Ronzoni, S, Costarella, M, Donadio, C, Battista, L, Renzulli, G, Gentile, G, Zuccaro, SM. Recurrent syncope in elderly patients and tilt test table outcome: the role of comorbidities. Archives Gerontol Geriatrics 2009; 49 suppl 1: 231–36.CrossRefGoogle ScholarPubMed
65Paul, B, Gieroba, Z, Mangoni, AA. Influence of comorbidities and medication use on tilt table test outcome in elderly patients. Pacing Clin Electrophysiol 2007; 30: 540–43.CrossRefGoogle ScholarPubMed
66Parry, SW, Reeve, P, Lawson, J, Shaw, FE, Davison, J, Norton, Met al.The 4 Newcastle protocols 2008: an update on head-up tilt table testing and the management of vasovagal syncope and related disorders. Heart 2009; 95: 416–20.CrossRefGoogle Scholar
67Liu, J, Fang, P, Liu, Y, Lu, G, Li, Z, Li, X, Wang, Y. Duration of head-up tilt test for patients with suspected vasovagal syncope. Europace 2011; 13: 576–80.CrossRefGoogle ScholarPubMed
68Brignole, M, Alboni, P, Benditt, DG, Bergfeldt, L, Blanc, JJ, Thomsen, PEet al.Guidelines on management (diagnosis and treatment) of syncope-update 2004. Executive Summary. Eur Heart J 2004; 25: 2054–72.Google ScholarPubMed
69Parry, SW, Gray, JC, Newton, JL, Reeve, P, O'Shea, D, Kenny, RA. Front-loaded head-up tilt table testing: validation of a rapid first line nitrate-provoked tilt protocol for the diagnosis of vasovagal syncope. Age Ageing 2008; 37: 411–15.CrossRefGoogle ScholarPubMed
70Timoteo, AT, Oliveira, MM, Feliciano, J, Antunes, E, Nogueira da Silva, M, Silva, Set al.Head-up tilt testing with different nitroglycerin dosages: experience in elderly patients with unexplained syncope. Europace 2008; 10: 1091–94.CrossRefGoogle ScholarPubMed
71De Castro, RR, Da Nobrega, AC. Elderly patients with unexplained syncope: what should be considered a positive tilt test response? Autonomic Neurosci – Basic & Clinical 2006; 126–27; 169–73.CrossRefGoogle ScholarPubMed
72Yiu, D, Gieroba, Z, Hall, K, Mackintosh, S, Russell, A, Mangoni, AA. An early drop in systolic blood pressure predicts a positive tilt table test in elderly patients with unexplained falls or syncope. Age Ageing 2006; 35: 183–85.CrossRefGoogle ScholarPubMed
73Parry, SW, Norton, M, Pairman, J, Baptist, M, Wilton, K, Reeve, Pet al.Impedance cardiography: a role in vasovagal syncope diagnosis? Age Ageing 2009; 38: 718–23.CrossRefGoogle ScholarPubMed
74Parry, SW, Matthews, I. The implantable loop recorder in older patients with syncope: is sooner better? Age Ageing 2010; 39: 284–85.CrossRefGoogle ScholarPubMed
75Moya, A, Sutton, R, Ammirati, Fet al.Guidelines on diagnosis and management of syncope. Eur Heart J 2009; 30: 2631, e71.Google ScholarPubMed
76Brignole, M, Menozzi, C, Moya, Aet al.; ISSUE Investigators. Non-arrhythmic syncope doumented by an implantable loop recorder (an ISSUE sub-study). Am J Cardiol 2002; 90: 654, e7.CrossRefGoogle Scholar
77Brignole, M, Sutton, R, Menozzi, C, Garcia-Civera, R, Moya, A, Wieling, Wet al. for the International Study on Syncope of Uncertain Etiology 2 (ISSUE 2) Group. Early application of an implantable loop recorder allows effective specific therapy in patients with recurrent suspected neutrally mediated syncope. Eur Heart J 2006; 27: 1085–92.CrossRefGoogle Scholar
78Edvardsson, N, Frykman, N, Van Mechelen, V, Mitro, R, Mohii-Oskarsson, P, Pasquie, Aet al.Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry. Europace 2011; 13: 262–69.CrossRefGoogle ScholarPubMed
79Petkar, S, Iddon, P, Bell, W, Rice, N, Mckee, D, Curtis, N, Cooper, P, Fitzpatrick, A. Reveal in the Investigation of Syncope and Epilepsy study. Eur Heart J 2009; 30: 0195–668X.Google Scholar
80Gupta, D, Molina, E, Palma, J, Macha, M. Massive right atrial myxoma presenting with syncope. Heart and Vessels 2006; 21: 256–57.CrossRefGoogle ScholarPubMed
81Van der Velde, N, Stricker, BHC, Roelandt, JRTC, Ten Cate, FJ, van der Cammen, TJM. Can echocardiographic findings predict falls in older persons? PLoS ONE 2007; 2: e654. doi:10.1371/journal.pone.0000654.CrossRefGoogle ScholarPubMed
82Linzer, M, Pritchett, EL, Pontinen, M, McCarthy, E, Divine, GW. Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope. Am J Cardiol 1990; 66: 214–19.CrossRefGoogle ScholarPubMed
83Senard, JM, Chamontin, B, Rascol, A, Montastruc, JL. Ambulatory blood pressure in patients with Parkinson's disease without and with orthostatic hypotension. Clin Auton Res 1992; 2: 99–104.CrossRefGoogle ScholarPubMed
84Parisi, Q, Messano, L, Santamaria, M, Angeloni, G, Digiannuario, G, Ciccarone, AMet al.A positive correlation between the cardio-inhibitory response to head-up tilt test and the asystole induced by adenosine triphosphate administration in patients with neurally-mediated vasovagal syncope. J Cardiovasc Electrophysiol 2009; 20: 235–41.Google Scholar
85Van Dijk, N, Quartieri, F, Blanc, JJ, Garcia-Civera, R, Brignole, M, Moya, A, Wieling, W, PC-Trial Investigators. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope. J Am Coll Cardiol 2006; 48:1652–57.CrossRefGoogle ScholarPubMed
86Di Girolamo, E, Di Iorio, C, Leonzio, L, Sabatini, P, Barsotti, A. Usefulness of a tilt training program for the prevention of refractory neurocardiogenic syncope in adolescents: a controlled study. Circulation 1999; 100: 1798–801.CrossRefGoogle ScholarPubMed
87Gajek, J, Zysko, D, Mazurek, W. Efficacy of tilt training in patients with vasovagal syncope. Kardiologia Polska 2006; 64: 602–8.Google ScholarPubMed
88Shaw, FE, Bond, J, Richardson, DA, Dawson, P, Steen, IN, McKeith, IG, Kenny, RA. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. Br Med J 2003; 326: 73–80.CrossRefGoogle Scholar
89Bannister, R, Mathias, CJ. Management of postural hypotension in autonomic failure. In Autonomic Nervous System: A Testbook of Clinical Disorders of the Autonomic Nervous System, ed. Bannister, R.London, Oxford University Press, 1993; pp. 589–90.Google Scholar
90Raj, SR, Rose, S, Ritchie, D, Sheldon, RS, Investigators, PI. The Second 35 Prevention of Syncope Trial (POST II) – a randomized clinical trial of fludrocortisone for the prevention of neurally mediated syncope: rationale and study design. Am Heart J 2006; 151: 1186, e11–7.CrossRefGoogle Scholar
91Kaufmann, H, Saadia, D, Voustianiouk, A. Midodrine in neurally mediated syncope: a double-blind, randomized, crossover study. Ann Neurol 2002; 52: 342–45.CrossRefGoogle ScholarPubMed
92Di Girolamo, E, Di Iorio, C, Sabatini, P, Leonzio, L, Barbone, C, Barsotti, A. Effects of paroxetine hydrochloride, a selective serotonin reuptake inhibitor, on refractory vasovagal syncope: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol 1999; 33: 1227–30.CrossRefGoogle ScholarPubMed
93Sud, S, Massel, D, Klein, GJ, Leong-Sit, P, Yee, R, Skanes, AC, Gula, LJ, Krahn, AD.The expectation effect and cardiac pacing for refractory vasovagal syncope. Am J Med 2007; 120: 54–62.CrossRefGoogle ScholarPubMed
94Kozak, LJ, Owings, MF, Hall, MJ. National Hospital Discharge Survey: 2002 annual summary with detailed diagnosis and procedure data. Vital Health Stat 13. 2005; 158: 1–199.Google Scholar
95Toff, WD, Camm, AJ, Skehan, JD. The United Kingdom Pacing and Cardiovascular Events (UKPACE) Trial Investigators. Single-chamber versus dual-chamber pacing for high-grade atrioventricular block. N Engl J Med 2005; 353: 145–55.CrossRefGoogle Scholar
96Lamas, GA, Lee, KL, Sweeney, MOet al.Mode Selection Trial in Sinus Node Dysfunction. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med 2002; 346: 1851–62.CrossRefGoogle ScholarPubMed
97Kenny, RA, Richardson, DA, Steen, Net al.Carotid sinus syndrome: a modifiable risk factor for non accidental falls in older adults (SAFE PACE). J Am Coll Cardiol 2001; 38: 1491–96.CrossRefGoogle ScholarPubMed
98Ryan, DJ, Nick, S, Colette, SM, Roseanne, K. Carotid sinus syndrome, should we pace? A multicentric, randomised control trial – Safe Pace 2. Heart 2010; 96: 347–51.CrossRefGoogle Scholar
99Maggi, R, Menozzi, C, Brignole, Met al.Cardio-inhibitory carotid sinus hypersensitivity predicts an asystolic mechanism of spontaneous neurally mediated syncope. Europace 2007; 9: 563–67.CrossRefGoogle Scholar
100Kaszala, K, Kalahasty, G, Ellenbogen, K. Cardiac pacing in the elderly. Am J Geriatr Cardiol 2006; 15: 77–81.CrossRefGoogle ScholarPubMed
101Maas, R, Ventura, R, Kretzschmar, C, Aydin, A, Schuchert, A. Syncope, driving recommendations, and clinical reality: survey of patients. Br Med J 2003; 326: 21.CrossRefGoogle ScholarPubMed
102DVLA. For Medical Practitioners: At a Glance. Guide to Current Medical Standards for Fitness to Drive. Drivers Medical Group, DVLA, Swansea, UK. May 2012, with amendments August 2012.Google Scholar