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Carotid sinus massage (CSM) can be helpful in any patient >_40 years old with symptoms suggestive of carotid sinus syndrome (CSS): syncope or near syncope elicited by tight collars, shaving, or turning the head.66,67 Methodology and response to CSM are described in section 4.1 in the Supplementary data. Diagnosis of CSS requires both the reproduction of spontaneous symptoms during CSM and clinical features of spontaneous syncope compatible with a reflex mechanism.6870

4.2 Electrocardiogram

Together with the history and physical examination, the resting ECG is an essential component of the initial evaluation of patients with documented or suspected bradycardia. A 12-lead ECG or a rhythm strip during the symptomatic episode provides the definitive diagnosis. For those in whom physical examination suggests a bradycardia, a 12-lead ECG is useful to confirm the rhythm, rate, nature, and extent of conduction disturbance (Supplementary Table 1). Furthermore, an ECG may provide information about structural heart or systemic illness (e.g. LV hypertrophy, Q waves, prolonged QT interval, and low voltage) that predict adverse outcomes in symptomatic patients.62

4.3 Non-invasive evaluation

Table 7 Intrinsic and extrinsic causes of bradycardia

Sinus bradycardia or SND AVJ disturbances

Intrinsic Idiopathic (ageing, degenerative) 1 1 Infarction/ischaemia 1 1 Cardiomyopathies 1 1 Genetic disorders 1 1 Infiltrative diseases

Sarcoidosis 1 1 Amyloidosis 1 1 Haemochromatosis 1 1 Collagen vascular diseases

Rheumatoid arthritis 1 1 Scleroderma 1 1 Systemic lupus erythematosus 1 1 Storage diseases 1 1 Neuromuscular diseases 1 1 Infectious diseases

Endocarditis (perivalvular abscess) – 1 Chagas disease 1 1 Myocarditis – 1 Lyme disease – 1 Diphtheria – 1 Toxoplasmosis – 1 Congenital heart diseases 1 1 Cardiac surgery

Coronary artery bypass grafting 1 1 Valve surgery (including transcatheter aortic valve replacement) 1 1 Maze operation 1 – Heart transplant 1 1 Radiation therapy 1 1 Intended or iatrogenic AVB – 1 Sinus tachycardia ablation 1 – Extrinsic Physical training (sports) 1 1 Vagal reflex 1 1 Drug effects 1 1 Idiopathic paroxysmal AVB – 1 Electrolyte imbalance

Hypokalaemia 1 1 Hyperkalaemia 1 1 Hypercalcaemia 1 1 Hypermagnesaemia 1 1 Metabolic disorders

Hypothyroidism 1 1 Anorexia 1 1 Hypoxia 1 1 Acidosis 1 1

Continued Table 7 Continued Sinus bradycardia or SND AVJ disturbances

Hypothermia 1 1 Neurological disorders

Increased intracranial pressure 1 1 Central nervous system tumours 1 1 Temporal epilepsy 1 1 Obstructive sleep apnoea 1 1 AV = atrioventricular; AVB = atrioventricular block; AVJ = atrioventricular junction; SND = sinus node dysfunction. Adapted from Mangrum et al.71 and Da Costa et al.72a

Recommendations for non-invasive evaluation

Recommendations Classa Levelb Once carotid stenosis is ruled out,c CSM is recommended in patients with syncope of unknown origin compatible with a reflex mechanism or with symptoms related to pressure/manipulation of the carotid sinus area.6870 I B

CSM = carotid sinus massage. aClass of recommendation. bLevel of evidence. cCSM should not be undertaken in patients with previous transient ischaemic attack, stroke, or known carotid stenosis. Carotid auscultation should be performed before CSM. If a carotid bruit is present, carotid ultrasound should be performed to exclude the presence of carotid disease. ESC 2021 ESC 2021

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