The Role of Pacing in Elderly Patients with Unexplained Syncope

Purpose of Review: To discuss the role of pacing in elderly patients with unexplained syncope. Recent Findings: In patients with recurrent syncope with suspected reflex mechanism, the decision of pacemaker implantation can be guided by a standardized algorithm which includes carotid sinus massage, tilt-table testing, and implantable loop recorder. Cardiac pacing may reduce recurrent syncope in cardioinhibitory carotid sinus syndrome. In select elderly patients with recurrent cardioinhibitory vasovagal syncope, cardiac pacing may also reduce syncope recurrence. There is no role of cardiac pacing in patients with without a cardioinhibitory response. There is increasing evidence that closed loop stimulation reduces the recurrence of cardioinhibitory vasovagal syncope. In patients with syncope and a positive electrophysiology study consistent with sinoatrial or conduction system disease, cardiac pacing has been shown to reduce recurrent syncope. Cardiac pacing is also effective in reducing recurrent syncope when high-grade atrioventricular block is documented on electrocardiography monitoring. In elderly patients with unexplained syncope and bundle branch block on ECG, diagnostic algorithm should be followed according to guidelines; empirical pacing is generally not recommended. Summary: Permanent pacemaker implantation may be effective to reduce recurrent syncope in select groups of elderly patients. It is important to consider additional investigations to evaluate elderly patients with unexplained syncope. The results of these testing would guide the decision on permanent pacemaker implantation.