Pacing interventions for falls and syncope in the elderly

There is a high prevalence of cardiovascular disorders among elderly patients with recurrent falls or syncope, and cardiovascular causes are implicated in a significant proportion of these cases. Common cardiovascular causes of falls and syncope include carotid sinus syndrome, vasovagal episodes, sick sinus syndrome, and atrioventricular block. A comprehensive history and physical examination supplemented by electrocardiographic monitoring, carotid sinus massage, and tilt-table testing in appropriately selected patients form the basis of the diagnostic evaluation to exclude a significant cardiovascular disorder. Patients with documented symptomatic bradycardia often benefit from pacemaker implantation, as evidenced by a reduction in recurrent events and improved quality of life. Although dual-chamber pacemakers, particularly those with rate responsiveness, provide more physiologic pacing than single-chamber ventricular devices, the superiority of dual-chamber pacemakers in reducing major clinical events has not been demonstrated. The efficacy of an aggressive evaluation and patient-management strategy that includes pacemaker implantation for elderly patients with recurrent falls has been validated only by one prospective clinical trial; however, available data are compelling. For a variety of cardiovascular conditions, permanent pacemaker implantation has a demonstrated efficacy to prevent symptoms that arise from transient hypotension and decreased cerebral perfusion. The implication of these data is that many falls may be preventable through permanent pacemaker implantation in appropriately selected patients.