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QUESTION: In older adults with cardioinhibitory carotid sinus hypersensitivity (CSH) presenting with a non-accidental fall (defined as coming to rest on the ground or another lower level not because of an accident or known medical cause), does cardiac pacing reduce subsequent non-accidental falls?
Design
Randomised (unclear allocation concealment*), unblinded,*controlled trial with 1 year of follow up.
Setting
A hospital in Newcastle upon Tyne, UK.
Patients
175 patients ≥ 50 years of age (mean age 73 y, 59% women) with cardioinhibitory CSH who reported to the emergency department because of a non-accidental fall. Exclusion criteria included cognitive impairment (Mini-Mental State Examination score < 24), a medical cause for the fall within 10 days of presentation, an accidental fall, blindness, contraindication to carotid sinus massage (CSM), and use of drugs known to cause hypersensitivity to CSM. Follow up was 91%.
Intervention
Patients were allocated to receive a rate-drop response physiological dual chamber pacemaker implant (n=87) or standard (non-pacing) treatment (n=88).
Main outcome measures
Number of falls without loss of consciousness and episodes of syncope.
Main results
Patients with pacemakers had fewer falls without loss of consciousness than did those in the control group (mean 4.1/y v 9.3/y, odds ratio 0.42, 95% CI 0.23 to 0.75). The groups did not differ for episodes of syncope (p=0.063).
Conclusion
In older adults presenting with a non-accidental fall and cardioinhibitory carotid sinus hypersensitivity, cardiac pacing reduced subsequent non-accidental falls.
Commentary
In elderly people, falls can lead to substantial morbidity and mortality.1 Furthermore, CSH is a frequent cardiovascular cause of syncope.2
In this study by Kenny et al, the incidence of falls in patients who received a pacemaker was reduced by 70%. Only those with a history of recurrent falls had a reduced incidence of syncope; overall, the groups did not differ for reduction in syncope.
Older adults who present with falls or syncope should be thoroughly evaluated. Studies have shown that the diagnostic yield of a comprehensive multidisciplinary assessment is high.3 This finding has profound medical, psychological, and economic importance. Cardiovascular causes remain the most common cause of syncope and signify a poor prognosis. Iatrogenic causes usually related to polypharmacy should be identified and rectified.
Although pacing is a simple intervention with a considerable beneficial effect in this patient population, only 16% of patients had a cardioinhibitory or mixed response that qualified them to receive a permanent pacemaker. 80% of patients who had syncope during carotid sinus massage had amnesia, raising the possibility that syncope may be more prevalent in patients who present with falls.
In establishing the efficacy of cardiac pacing for falls related to CSH, this study points to the need to look for this disorder in elderly people presenting with non-accidental falls.
Footnotes
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Sources of funding: National Health Service Cardiovascular Research World Development Programme; Research into Ageing; Medtronic.
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For correspondence: Professor R A Kenny, Royal Victoria Infirmary, Newcastle upon Tyne, UK. r.a.kenny{at}ncl.ac.uk.