a b s t r a c t

Objective: The objectives of our investigation were to review the evidence for the efficacy and safety of Carotid sinus massage in terminating supraventricular tachycardia and to determine if other potentially less harmful in- terventions have been established to be safer and more effective.

Methods: A search using PubMed, Ovid, and COCHRANE databases was performed using the terms supraventricular tachycardia, carotid sinus massage, SVT, and CSM. Articles not written in English were excluded. There was a paucity of randomized controlled trials comparing various supraventricular tachycardia interventions. However, arti- cles of highest quality were selected for review and inclusion. In addition, articles examining potential hazards of ca- rotid sinus massage in case report format were reviewed, even when performed for other indications other than SVT, as the maneuver is identically performed. Selected articles were reviewed by both authors for relevance to the topic. Results: Summarizing the findings of this review leads to these 3 fundamental conclusions. First, a therapeutic inter- vention should only be performed when the benefit of the procedure outweighs its risk. Carotid sinus massage ex- poses the patient to rare but potentially devastating iatrogenic harm. Second, a therapeutic intervention should be efficacious. The efficacy of carotid sinus massage in terminating supraventricular tachycardia appears to be modest at best. Third, other readily available, easily mastered, and potentially safer and more efficacious alternative interven- tions are available such as Valsalva maneuver and Pharmacologic therapy.

Conclusion: Based on the limited evidence available, we believe that carotid sinus massage should be reconsidered as a first-line therapeutic intervention in the termination of SVT.

(C) 2015

Introduction

Patients with symptomatic and persistent supraventricular tachy- cardia (SVT) commonly present to the emergency department (ED). Al- though readily available and relatively safe pharmacologic agents have proven to be effective in terminating these arrhythmias, emergency medicine clinicians may attempt vagus nerve stimulation techniques as the initial therapeutic intervention. These typically include Valsalva maneuvers, facial ice water immersion, and carotid sinus massage.

Digital carotid sinus massage, which stimulates the carotid sinus lo- cated in the anterosuperior area of the neck, has been used as a diagnos- tic test and therapeutic intervention for over 2 centuries. It traditionally has been used in the evaluation of syncope and the treatment of tachydysrhythmias. Although a number of widely referenced and accessed emergency medicine textbooks advocate carotid sinus

? The authors have no commercial associations or sources of support that might pose a conflict of interest. Both authors have made substantive contributions to the study and en- dorse the data and conclusions.

?? This study did not receive external funding.

* Corresponding author. Tel.: +1 207 662 1452; fax: +1 207 662 7025.

E-mail addresses: [email protected] (N.A. Collins), [email protected] (G.L. Higgins).

¹ Tel.: +1 207 662 1452; fax: +1 207 662 7025.

massage in the management of SVT, only one actually describes the pro- cedure [1], whereas others simply list it as an option without further discussion of technique [2,3].

A recent review article comprehensively examined the safety of ca- rotid sinus massage [4]. The authors report up to a 1% neurologic compli- cation rate associated with the maneuver. Reported complications ranged from mild dysarthria and visual field defects to dense hemiplegia. The postulated mechanism of massage-associated complications is traumatic fissuring of atherosclerotic plaques in the carotid artery endo- thelium. The resultant fresh clot that forms in situ is strategically posi- tioned to embolize to the brain. Unfortunately, the presence of a carotid bruit is not a reliable test to risk stratify patients. The authors

recommend against performing carotid sinus massage in the elderly.

The objectives of our investigation were to review the evidence for the efficacy and safety of carotid sinus massage in terminating SVT and to determine if other potentially less harmful interventions have been established to be safer and more effective.

Search strategy

A search using PubMed, Ovid, and COCHRANE databases was per- formed using the terms supraventricular tachycardia, carotid sinus

http://dx.doi.org/10.1016/j.ajem.2015.02.047

0735-6757/(C) 2015

808 N.A. Collins, G.L. Higgins III / American Journal of Emergency Medicine 33 (2015) 807-809

massage, SVT, and CSM. Articles not written in English were excluded. There was a paucity of randomized controlled trials comparing various SVT interventions. However, articles of the highest quality were select- ed for review and inclusion. Additionally, articles examining potential hazards of carotid sinus massage in case report format were reviewed, even when performed for other indications other than SVT, as the ma- neuver is identically performed. Selected articles were reviewed by both authors for relevance to the topic.

Article summaries

Lim et al [5]

This was a prospective randomized controlled trial comparing Valsalva maneuver to carotid sinus massage in the termination of SVT in ED patients. One hundred forty-eight patients were included in the study. They were initially randomized to receive one of the study inter- ventions. If their initial randomized treatment was ineffective, the alter- native intervention was attempted. If both interventions were ineffective, the patient underwent electrical or pharmacologic termina- tion. Valsalva was performed by having the patient blow into a mouth- piece connected by a 6-in tube to a sphygmomanometer, with a target airway pressure of 40 mm Hg for at least 30 seconds. Carotid sinus mas- sage was performed by posteromedial compression with a massaging motion of the carotid sinus for 10 seconds. If unsuccessful, the other side was tried. The starting side was chosen at random.

Of the 86 patients randomized to initial carotid sinus massage, 9 (10.5%) converted to a sinus rhythm. When Valsalva maneuver was the initial intervention, 12 (19.4%) of 62 patients were successfully con- verted. Crossover treatment resulted in success in 13 (16.9%) of 77 ca- rotid sinus massage patients and 7 (14%) of 50 Valsalva maneuver patients. No adverse reactions were reported. The authors concluded that, overall, both Valsalva maneuver and carotid sinus massage inter- ventions had equivalent efficacy in approximately 25% of cases, with no statistical significant difference between the 2 treatments. Finally, it was observed with further data analysis that Valsalva maneuver ap- peared to be slightly more efficacious in male patients, whereas carotid sinus massage tended to be more beneficial in the older age groups.

Ballo et al [6] This study enrolled 106 patients with paroxysmal SVT and random-

ized them to receive intravenous verapamil 5 mg followed by a 1- to 5-ug/(kg min) infusion, intravenous adenosine 6 mg followed by 12 mg after 2 to 3 minutes if needed, or carotid sinus massage applied for at least 5 seconds on each side twice.

They found that there was similar effectiveness between verapamil (81.8%) and adenosine (74.4%) in terminating the dysrhythmia, with the interesting finding that adenosine appeared to be more efficacious with higher heart rates and verapamil with lower heart rates, with a graph comparison showing relative efficacy crossing at 173 beats per minute. Carotid sinus massage was much less efficacious, successful in only 32.4% of patients in this arm of the study. There were no significant complications for any patients involved in this study.

Mehta et al [7]

This study compared carotid sinus massage, water immersion, and Valsalva maneuver for the treatment of junctional tachycardia. The 35 stable study participants (20 men, mean age 35 years with range of 16 to 69 years) were patients referred by clinicians for electrophysiological assessment of paroxysmal SVT. All participants had been without any type of antiarrhythmic medication for at least 72 hours (and at least 3 months for patients using amiodarone).

Supraventricular tachycardia was induced artificially using pro- grammed electrical stimulation following a diagnostic electrophysiolog- ic study. After 5 minutes of SVT, each maneuver was performed in random order, 3 times apiece. The maneuver was considered successful if it terminated the arrhythmia in at least 2 of the 3 attempts.

Valsalva maneuver was performed with the patient in both supine and standing positions. A manometer was used to maintain a pressure of 35 mm Hg for 15 and 30 seconds. This intervention terminated the arrhythmia in 19 patients (54%), 15 of whom converted all 3 times it was attempted. The 15- and 30-second durations of the maneuver were performed similarly. The supine position was superior to the standing position.

Water immersion was performed with the patient in a sitting posi- tion. Water temperature was maintained between 5?C. and 7?C. Facial immersion was performed for 15 to 20 seconds. Successful arrhythmia conversion occurred in 6 (17%) patients.

Carotid sinus massage was performed for 5 seconds and applied to the superior portion of the carotid artery in the neck. Both sides were examined sequentially. Right-sided carotid sinus massage terminated the arrhythmia in 6 patients (17%), whereas the left-sided maneuver was successful in 2 patients (5%).

It was concluded that the supine Valsalva maneuver was superior to the other 2 interventions. There were no intervention-related complica- tions in any of the 35 study participants.

Richardson et al [8]

This prospective observational study examined the types and rates of complications associated with carotid sinus massage performed for the purpose of diagnosing carotid sinus hypersensitivity in patients older than 50 years. Although this study employed carotid sinus mas- sage for a different indication, the technique of massage was similar to that described in reports of carotid sinus massage performed to treat SVT. Longitudinal massage was performed for 5 seconds over the most prominent carotid impulse. The right carotid artery was initially mas- saged. Following a 30-second pause, the left carotid artery was then massaged. One thousand patients were included in the study.

There were no reported cardiac arrhythmias, predefined as SVT, ven- tricular tachycardia, or ventricular fibrillation of any duration. There were also no reported episodes of high-degree heart block or asystole. There were, however, 9 (0.9%) neurologic complications temporally re- lated to carotid sinus massage. The median age of these patients was

69.7 years. Eight had relatively minor and transient neurologic com- plaints: visual disturbance, motor weakness, and paresthesia. However, 1 patient experienced persistent right-hand deficit.

Numerous case reports describe significant complications associated with carotid sinus massage. The following are briefly reviewed as repre- sentative of the 3 general types of reported adverse events: local ana- tomic, neurologic, and arrhythmogenic.

Thomas et al [9]

A 28-year-old man with chronic kidney disease presented to an ED with SVT and received carotid sinus massage. Thirty minutes following this, he experienced hoarseness and neck pain. Laryngoscopy identified vocal cord paralysis and a perithyroid hematoma. He was treated con- servatively, only to present 5 days later with neck fullness, stridor, and dyspnea. Neck exploration revealed a retroEsophageal hematoma re- quiring evacuation. Uremia-related platelet dysfunction was believed to be a contributing factor for this complication.

Ferguson and Ellis [10]

A 68-year-old man with a prior history of SVT developed a recurrent episode postoperatively. Carotid sinus massage was performed on the right side, which was unsuccessful and resulted in the patient experiencing left-hand tingling and heaviness that soon progressed to complete left-arm motor loss. His SVT was treated effectively with ve- rapamil. Carotid Doppler studies revealed no significant atherosclerotic disease. Neuroimaging performed a week later demonstrated a small in- farct of the right internal capsule and caudate nucleus. His symptoms re- solved over the next 2 weeks.

Cohen [11]

A 66-year-old man with prior history of recurrent SVT developed an episode postoperatively. Carotid sinus massage produced ventricular fi- brillation and ventricular tachycardia. Emergent electrical defibrillation was required.

N.A. Collins, G.L. Higgins III / American Journal of Emergency Medicine 33 (2015) 807-809 809

The bottom line

On the basis of the limited evidence available, we believe that carotid sinus massage should be reconsidered as a first-line therapeutic interven- tion in the termination of SVT. We base this recommendation on 3 funda- mental considerations. First, a therapeutic intervention should only be performed when the benefit of the procedure outweighs its risk. Carotid sinus massage exposes the patient to rare but potentially devastating iat- rogenic harm. Second, a therapeutic intervention should be efficacious. The efficacy of carotid sinus massage in terminating SVT appears to be modest at best. Third, other readily available, easily mastered, and poten- tially safer and more efficacious alternative interventions are available such as Valsalva maneuver and pharmacologic therapy.

References

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