Case Report| Volume 26, ISSUE 6, P423-425, December 2022

A case of vasovagal syncope associated with carotid sinus hypersensitivity: Effectiveness of tilt training and subsequent squatting


      A 43-year-old man fainted on a train and was transported to our hospital by an ambulance. No structural heart diseases or neurological abnormalities were observed. Electrocardiogram on admission demonstrated a junctional escape rhythm with bradycardia at 39 bpm. Sick sinus syndrome was excluded from electrophysiological studies. He had lifelong episodes of recurrent syncope that occurred due to emotional stress in daily life and pain associated with medical procedures. Since both the head-up tilt and carotid sinus massage tests showed a positive response, he was diagnosed with vasovagal syncope (VVS) and carotid sinus hypersensitivity. He was encouraged to continue the modified tilt training at home, which included leaning on the wall and squatting if leaning was intolerant. Thereafter, syncope was not observed in his daily life. This case highlights the importance of an accurate diagnosis, full education, and home training for recurrent syncope. This case also suggests that the carotid sinus may be involved in the neural network that causes VVS.

      Learning objective

      Reflex syncope includes both vasovagal syncope (VVS) and carotid sinus syndrome (CSS); however, VVS is discriminated from CSS according to current guidelines. We encountered a case of VVS associated with carotid sinus hypersensitivity. Recurrent syncope disappeared with modified tilt training characterized by conventional tilting and subsequent squatting when tilting was intolerant. This case indicates that the carotid sinus may be involved in the neural network responsible for VVS.


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        • Goldberger Z.D.
        • Petek B.J.
        • Brignole M.
        • Shen W.K.
        • Sheldon R.S.
        • Solbiati M.
        • Deharo J.C.
        • Moya A.
        • Hamdan M.H.
        ACC/AHA/HRS versus ESC guidelines for the diagnosis and management of syncope: JACC guideline comparison.
        J Am Coll Cardiol. 2019; 74: 2410-2423
        • Maggi R.
        • Menozzi C.
        • Brignole M.
        • Podoleanu C.
        • Iori M.
        • Sutton R.
        • Moya A.
        • Giada F.
        • Orazi S.
        • Grovale N.
        Cardioinhibitory carotid sinus hypersensitivity predicts an asystolic mechanism of spontaneous neutrally mediated syncope.
        Europace. 2007; 9: 563-567
        • Di Girolamo E.
        • Di Iorio C.
        • Leonzio L.
        • Sabatini P.
        • Barsotti A.
        Usefulness of a tilt training program for the prevention of refractory neurocardiogenic syncope in adolescents: a controlled study.
        Circulation. 1999; 100: 1798-1801
        • Gajek J.
        • Zyśko D.
        • Mazurek W.
        Efficacy of tilt training in patients with vasovagal syncope.
        Kardiol Pol. 2006; 64: 602-610
        • Ector H.
        • Willems R.
        • Heidbüchel H.
        • Reybrouck T.
        Repeated tilt testing in patients with tilt-positive neurally mediated syncope.
        Europace. 2005; 7: 628-633
        • Kinay O.
        • Yazici M.
        • Nazli C.
        • Acar G.
        • Gedikli O.
        • Altinbas A.
        • Kahraman H.
        • Dogan A.
        • Ozaydin M.
        • Tuzun N.
        • Ergene O.
        Tilt training for recurrent neurocardiogenic syncope: effectiveness, patient compliance, and scheduling the frequency of training sessions.
        Jpn Heart J. 2004; 45: 833-843
        • Foglia-Manzillo G.
        • Giada F.
        • Gaggioli G.
        • Bartoletti A.
        • Lolli G.
        • Dinelli M.
        • Del Rosso A.
        • Santarone M.
        • Raviele A.
        • Brignole M.
        Efficacy of tilt training in the treatment of neurally mediated syncope. A randomized study.
        Europace. 2004; 6: 199-204
        • On Y.K.
        • Park J.
        • Huh J.
        • Kim J.S.
        Is home orthostatic self-training effective in preventing neurally mediated syncope?.
        PACE. 2007; 30: 638-643
        • Duygu H.
        • Zoghi M.
        • Turk U.
        • Akyuz S.
        • Ozerkan F.
        • Akilli A.
        • Erturk U.
        • Onder R.
        • Akin M.
        The role of tilt training in preventing recurrent syncope in patients with vasovagal syncope: a prospective and randomized study.
        PACE. 2008; 31: 592-596
        • Podd S.
        • Hunt J.
        • Sulke N.
        Home orthostatic training in elderly patients with vasovagal syncope: a prospective randomized controlled trial.
        Eur Cardiol. 2015; 10: 123-127