Age and Ageing (1975), 4, 86
CARDIAC EFFECTS OF CAROTID SINUS MASSAGE IN OLD AGE G. D. MANKIKAR AND A. N. G. CLARK
Brighton General Hospital, Brighton, Sussex
The effects of carotid sinus massage in aged subjects with a high incidence of arteriosclerosis are described. In 71 men and 315 women tested, a slowing of more than 10 per cent of the heart rate was found in 25 per cent of the men and 19 per cent of the women, which is not of statistical significance in relation to sex. Only men showed a significant increase with age and the women had a significant preponderance of a right-sided response. The technique was found to be safe, although a review of reported side-effects suggests care is advisable and carotid compression must not occur. The findings are discussed in relation to those reported in younger subjects and in carotid sinus syndrome with syncope. The fact that men have an acquired increase in response in old age, which is not seen in women, may be a factor of importance in the explanation of why carotid sinus syncope is almost always seen in men. Carotid sinus sensitivity appears to diminish in old age and some of the ageing factors which might influence the carotid sinus reflex are examined. The phenomenon of cardiac slowing following pressure over the bifurcation of the common carotid artery was first observed by Parry in 1799. This was originally believed to be mediated by direct pressure on the vagus nerve, but Hering, nearly 50 years ago (1927), recognized the reflex nature of carotid sinus stimulation. Since then, the physiological and pathological effects of carotid sinus massage upon the heart and circulation have been described (Sigler, \933a,b, 1934). Almost all observations have been made on subjects in earlier life and in middle age (Sigler, 1941; Nathanson, 1946), with few data for over the age of 80 years. The series of Smiddy, Lewis & Dunn (1972) is the only specific study in the aged but is confined to men. This paper reports the findings in a selected group of very old persons of both sexes. Method Observations were made on in-patients in the assessment and long-stay wards of the Geriatric Unit and the technique advocated by Thomas (1969) and Arenberg et al. (1971) was followed with precautions to ensure that there was no risk to the subjects. The carotid sinuses were first carefully auscultated; in 6 instances (2 men and 4 women) bruits were heard and the test was abandoned because of the dangers of embolism. After permission, all the tests were performed with moderate pressure and the greatest care taken to prevent carotid compression. It is not possible to quantify the pressure used, as accurate methods of measurement do not exist, however, we tried to produce a standard technique in which the response would be comparable within the series. The subjects were in bed with the neck slightly extended and rotated to the opposite side, being supported by three pillows. Whilst counting the heart rate by auscultation, the line of the bifurcation of the common carotid artery was gently massaged with the middle three fingers of the observer's right hand. The test was repeated in those whose heart rate slowed with the effects recorded on Lead 2 of the
Downloaded from http://ageing.oxfordjournals.org/ at Emory University on March 22, 2016
Summary
Cardiac Effects of Carotid Sinus Massage in Old Age
87
electrocardiograph. The degree of slowing was expressed as a percentage of the resting rate and classified in three grades: (a) More than 10 per cent and less than 50 per cent of the original rate. (b) More than 50 per cent of the original rate. (c) Cardiac asystole for more than two seconds; the test was stopped when this occurred. A reduction of heart rate of more than 10 per cent was taken as a positive response, as lesser degrees of slowing are difficult to measure and could be physiological. The findings were examined for significance by standard statistical tests.
Tests were made on 71 men and 315 women, aged 62-104 years; of these 35 men and 213 women were over 80 years of age. Many were suffering from long-standing and multiple disabilities and 54 per cent of the men and 45 per cent of the women had clinical evidence of gross degenerative arterial disease. Over-all Response by Age and Sex
Table I shows the incidence of response related to age by decade and sex. The apparently higher incidence of sensitivity for men compared with women is not of statistical significance. The men showed a significant increase with age (P< 0.01) with no similar trend in women. Table I. Carotid sinus response by age and sex Female (315;)
Male (71) years
Total tested
Response positive
61/70 71/80 81/90 91/100 100 + Total
17 19 30 5 — 71
3 13 2 — 18
Age
Percentage 15.8 43.3 40.0 —
25.3
Total tested
Response positive
Percentage
27 75 156 53 4 315
5 17 23 14 2 61
18.5 22.6 14.8 26.4 50.0 19.3
Degree of Slowing
Table II gives the findings in 18 men and 61 women who showed slowing in relation to sex, age by decade and the side of stimulation. The figures do not show statistical significance in the relation of degree of response or sex distribution, but the men show an increase in response with age that is significant (P
CARDIAC EFFECTS OF CAROTID SINUS MASSAGE IN OLD AGE G. D. MANKIKAR AND A. N. G. CLARK
Brighton General Hospital, Brighton, Sussex
The effects of carotid sinus massage in aged subjects with a high incidence of arteriosclerosis are described. In 71 men and 315 women tested, a slowing of more than 10 per cent of the heart rate was found in 25 per cent of the men and 19 per cent of the women, which is not of statistical significance in relation to sex. Only men showed a significant increase with age and the women had a significant preponderance of a right-sided response. The technique was found to be safe, although a review of reported side-effects suggests care is advisable and carotid compression must not occur. The findings are discussed in relation to those reported in younger subjects and in carotid sinus syndrome with syncope. The fact that men have an acquired increase in response in old age, which is not seen in women, may be a factor of importance in the explanation of why carotid sinus syncope is almost always seen in men. Carotid sinus sensitivity appears to diminish in old age and some of the ageing factors which might influence the carotid sinus reflex are examined. The phenomenon of cardiac slowing following pressure over the bifurcation of the common carotid artery was first observed by Parry in 1799. This was originally believed to be mediated by direct pressure on the vagus nerve, but Hering, nearly 50 years ago (1927), recognized the reflex nature of carotid sinus stimulation. Since then, the physiological and pathological effects of carotid sinus massage upon the heart and circulation have been described (Sigler, \933a,b, 1934). Almost all observations have been made on subjects in earlier life and in middle age (Sigler, 1941; Nathanson, 1946), with few data for over the age of 80 years. The series of Smiddy, Lewis & Dunn (1972) is the only specific study in the aged but is confined to men. This paper reports the findings in a selected group of very old persons of both sexes. Method Observations were made on in-patients in the assessment and long-stay wards of the Geriatric Unit and the technique advocated by Thomas (1969) and Arenberg et al. (1971) was followed with precautions to ensure that there was no risk to the subjects. The carotid sinuses were first carefully auscultated; in 6 instances (2 men and 4 women) bruits were heard and the test was abandoned because of the dangers of embolism. After permission, all the tests were performed with moderate pressure and the greatest care taken to prevent carotid compression. It is not possible to quantify the pressure used, as accurate methods of measurement do not exist, however, we tried to produce a standard technique in which the response would be comparable within the series. The subjects were in bed with the neck slightly extended and rotated to the opposite side, being supported by three pillows. Whilst counting the heart rate by auscultation, the line of the bifurcation of the common carotid artery was gently massaged with the middle three fingers of the observer's right hand. The test was repeated in those whose heart rate slowed with the effects recorded on Lead 2 of the
Downloaded from http://ageing.oxfordjournals.org/ at Emory University on March 22, 2016
Summary
Cardiac Effects of Carotid Sinus Massage in Old Age
87
electrocardiograph. The degree of slowing was expressed as a percentage of the resting rate and classified in three grades: (a) More than 10 per cent and less than 50 per cent of the original rate. (b) More than 50 per cent of the original rate. (c) Cardiac asystole for more than two seconds; the test was stopped when this occurred. A reduction of heart rate of more than 10 per cent was taken as a positive response, as lesser degrees of slowing are difficult to measure and could be physiological. The findings were examined for significance by standard statistical tests.
Tests were made on 71 men and 315 women, aged 62-104 years; of these 35 men and 213 women were over 80 years of age. Many were suffering from long-standing and multiple disabilities and 54 per cent of the men and 45 per cent of the women had clinical evidence of gross degenerative arterial disease. Over-all Response by Age and Sex
Table I shows the incidence of response related to age by decade and sex. The apparently higher incidence of sensitivity for men compared with women is not of statistical significance. The men showed a significant increase with age (P< 0.01) with no similar trend in women. Table I. Carotid sinus response by age and sex Female (315;)
Male (71) years
Total tested
Response positive
61/70 71/80 81/90 91/100 100 + Total
17 19 30 5 — 71
3 13 2 — 18
Age
Percentage 15.8 43.3 40.0 —
25.3
Total tested
Response positive
Percentage
27 75 156 53 4 315
5 17 23 14 2 61
18.5 22.6 14.8 26.4 50.0 19.3
Degree of Slowing
Table II gives the findings in 18 men and 61 women who showed slowing in relation to sex, age by decade and the side of stimulation. The figures do not show statistical significance in the relation of degree of response or sex distribution, but the men show an increase in response with age that is significant (P
