Cicogna R, Mascioli G, Bonomi F G, Turelli A, Morandi F, Curnis A, Visioli O
Cattedra e Divisione di Cardiologia, Università Degli Studi e Spedali Civili, Brescia.
G Ital Cardiol. 1993 Oct;23(10):985-93.
Carotid sinus hypersensitivity (CSH) has always been described in patients in sinus rhythm; we did not find reports of CSH in patients with chronic atrial fibrillation (AF). After the observation of bilateral CSH in a patient with chronic AF admitted to our Division for syncope, we began to systematically study patients with chronic AF and neurological disturbances to evaluate carotid sinus stimulation effects upon cardiac activity and arterial blood pressure in these subjects.
We studied 28 subjects with chronic AF (mean age 73.3 yrs.; range 60-89): 16 patients had dizziness, fainting or syncope, and formed the study group (A); 12 asymptomatic patients were considered the control group (B). After a careful clinical and instrumental evaluation, all the patients underwent a 24 hour ambulatory (Holter) ECG analysis and right and left carotid sinus massage (CSM). If the latter manoeuvre induced asystolia longer than 3 seconds, CSM was repeated during ventricular pacing to evaluate the vasal component of the carotid sinus reflex.
In group A, 24-hour Holter monitoring showed a greater incidence (81.2%) of ventricular standstill (mean duration 2.67 seconds) in comparison to the control group. In group A we found CSH in 75% of the cases, more frequently right CSH (7 subjects with right, 1 with left and 4 with bilateral CSH) with prolonged ventricular asystolia (mean duration 5.3 +/- 1.9 sec. with right CSM; 7.8 +/- 1.4 sec. with left CSM); during CSM, we reproduced spontaneous symptomatology in 9 patients. In 12 patients in group A, diagnosis of carotid sinus syndrome was established; the cardioinhibitory forms were clearly prevalent (91.7%); only one patient presented a cardioinhibitory-vasodepressor form with a predominant vasodepressor component.
The authors believe that CSH is frequent in patients with chronic AF; the vagal hyperactivity due to CSH can induce prolonged ventricular asystole that may be responsible for neurological disturbances such as dizziness, fainting or syncope, as observed in patients in sinus rhythm with carotid sinus syndrome. Abnormal sensitivity of the carotid sinus could thus be one of the causes of increased morbidity and mortality in patients with chronic AF. The majority of these patients may be expected to benefit from permanent pacemaker therapy.
颈动脉窦过敏（CSH）一直是在窦性心律患者中描述的；我们未发现慢性心房颤动（AF）患者中CSH的报道。在我们科室收治的一名因晕厥入院的慢性AF患者中观察到双侧CSH后，我们开始系统研究慢性AF和神经功能障碍患者，以评估颈动脉窦刺激对这些受试者心脏活动和动脉血压的影响。
我们研究了28例慢性AF患者（平均年龄73.3岁；范围60 - 89岁）：16例有头晕、昏厥或晕厥，组成研究组（A）；12例无症状患者为对照组（B）。经过仔细的临床和仪器评估后，所有患者均接受24小时动态（Holter）心电图分析以及左右颈动脉窦按摩（CSM）。如果后者操作诱发心脏停搏超过3秒，则在心室起搏期间重复CSM以评估颈动脉窦反射的血管成分。
在A组中，24小时Holter监测显示与对照组相比，心室停搏发生率更高（81.2%）（平均持续时间2.67秒）。在A组中，我们发现75%的病例存在CSH，右侧CSH更常见（7例右侧、1例左侧和4例双侧CSH），伴有心室停搏延长（右侧CSM时平均持续时间5.3±1.9秒；左侧CSM时为7.8±1.4秒）；在CSM期间，我们在9例患者中重现了自发症状。在A组的12例患者中，确立了颈动脉窦综合征的诊断；心脏抑制型明显占优势（91.7%）；只有1例患者表现为心脏抑制 - 血管减压型，以血管减压成分占主导。
作者认为CSH在慢性AF患者中很常见；CSH引起的迷走神经活动亢进可诱发心室停搏延长，这可能是导致神经功能障碍如头晕、昏厥或晕厥的原因，正如在窦性心律的颈动脉窦综合征患者中所观察到的那样。因此，颈动脉窦的异常敏感性可能是慢性AF患者发病率和死亡率增加的原因之一。这些患者中的大多数可能有望从永久性起搏器治疗中获益。
