Paroxysmal AV block Vagal Maneuvers :Carotid Sinus Massage and Tilt Table testing

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Vagal Maneuvers : Carotid Sinus massage and Tilt Table testing

  • Though not specific,tilt table testing (TT) and other vagal maneuvers such as the vasalva maneuver, eye ball pressure and immersing one's face in cold water can be used in the diagnosis of EV-AVB.
  • The Syncope Unit Project-2 study found an increase recurrence rate in patients who did not undergo tilt table testing. This highlights the utility of TT as a screening test for reflex syncope.
  • A positive response is indicated as a marker of hypotensive susceptibility which involves a decrease in both preload and afterload. [1]
  • Having said that, a negative test does not rule out the possibility of an extrinsic vagal paroxysmal AV block.
  • A carotid sinus massage is indicated in patients more than 40 years of age with syncope of unknown origin compatible with reflex mechanism.
    • Carotid sinus sensitivity is confirmed if carotid sinus massage causes bradycardia (asystole) and/or hypotension that reproduce spontaneous symptoms and patients have clinical features compatible with reflex mechanism of syncope. "ESC Guidelines on Syncope (Diagnosis and Management of)".
Carotid Sinus Massage- "ESC Guidelines on Syncope (Diagnosis and Management of)".


2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay

Carotid Sinus Massage and and Procainamide Challenge test

  • Carotid sinus massage and medication challenges can be used to identify the presence of paroxysmal atrioventricular block or determine the level of block in patients with second-degree block where the level of block is uncertain by electrocardiographic analysis alone (eg, 2:1 atrioventricular block or Mobitz type I atrioventricular block in the setting of a wide QRS complex).
  • One study showed that in patients with bifascicular block on ECG, a 15-ms increase in the His-ventricular (HV) interval or induced infranodal atrioventricular block with procainamide challenge was considered abnormal and possibly indicative of underlying infra-Hisian block.
  • The sensitivity of a procainamide challenge for distal conduction disease is low. However, it could be potentially useful in cases where the HV interval is borderline or atrioventricular block cannot be induced.
  1. ↑ Brignole M, Arabia F, Ammirati F, Tomaino M, Quartieri F, Rafanelli M; et al. (2016). "Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study". Europace. 18 (9): 1427–33. doi:10.1093/europace/euv343. PMID 26612880.
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