The carotid sinus reflexes

doi:10.1016/0002-8703(65)90138-9

American Heart Journal

Volume 70, Issue 1, July 1965, Pages 119-135

https://doi.org/10.1016/0002-8703(65)90138-9 Get rights and content

Abstract

Forty years have elapsed since Hering defined the carotid sinus reflex. Present theory indicates that the reflexes act by “buffering” the outflow from the brain of sympathetic and parasympathetic nervous system activity. Through changes in this autonomic nervous system outflow, decreases in systemic arterial pressure would be opposed by (a) decreases in the distensibility and volume of the systemic postarteriolar capacity vessels, (b) increases in cardiac work, and (c) increases in total peripheral resistance. Conversely, increases in arterial pressure would be opposed by effects in the opposite direction.

Until the last decade, baroreceptor experimental neurogenic hypertension was produced by bilateral carotid sinus denervation and partial vagotomy. The hypertension so caused was singularly unlike essential hypertension. It was very labile, and the increase in arterial pressure was associated with tachycardia and an elevation of cardiac output. However, since 1954, it has been clearly demonstrated that permanent, stable hypertension without tachycardia can readily be produced in dogs by bilaterally interfering with the carotid sinus reflexes alone (vagi intact). Furthermore, it has been shown that the carotid sinus reflexes may be of significance in the production of renal hypertension. Also, carotid sinus pacemakers have recently been shown to be capable of reducing blood pressure in hypertensive dogs and man.

It has been held for more than 30 years that spontaneous syncopal attacks are caused by stimulation of the carotid sinus reflexes. Nevertheless, in the great majority of patients with a diagnosis of carotid sinus syndrome, spontaneous syncope is not associated with an immediately apparent stimulation of the carotid sinus, such as direct pressure, a tight collar, shaving, or scratching. It is argued in the present communication that in those cases without apparent stimulation of the carotid sinus the diagnosis of carotid sinus syndrome cannot be made or classified by the tests presently employed. Even the results of surgical denervation cannot prove the existence of the carotid sinus syndrome in most cases.

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Cited by (21)

Carotid Sinus Nerve Blockade to Reduce Blood Pressure Instability Following Carotid Endarterectomy: A Systematic Review and Meta-analysis
2007, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
This initiates a reflex arc to the upper brainstem and produces a compensatory bradycardia and a subsequent lowering in blood pressure.11 Some vascular surgeons advocate nerve –sparing dissection and/or local anaesthetic blockade of the carotid sinus nerve at the time of CEA to minimise fluctuations in blood pressure,12 although the purported benefits are based primarily on animal studies13 and several randomised studies have refuted this assertion.14,15 Therefore the role of local anaesthetic infiltration into the carotid sinus during CEA to prevent post-operative haemodynamic instability remains unclear.
Local anaesthetic infiltration into the carotid sinus during carotid endarterectomy (CEA) has been recommended to minimise blood pressure fluctuations but its use remains controversial. The aim of this meta-analysis was to determine whether intra-operative administration of local anaesthetic reduces the incidence of haemodynamic instability following CEA.
A search of the Medline, Pubmed and Embase databases and the Current Controlled Trials register identified four trials, which met the pre-defined inclusion criteria for data extraction. Pooled odds ratios with 95 per cent confidence intervals (c.i.) for the development of post-operative hypotension and hypertension were calculated using a random-effects model.
Outcomes of 432 patients were studied. Local anaesthetic blockade of the carotid sinus was associated with a pooled odds ratio of 1.25 (95 per cent c.i. 0.496 to 3.15); p = 0.216) and 1.28 (95 per cent c.i. 0.699 to 2.33; p = 0.428) for the development of post-operative hypotension and hypertension respectively. Although none reach significance there was a trend towards increased risk of developing a complication in those patients who received local anaesthetic.
There are insufficient data to determine the role of intra-operative local anaesthetic administration in reducing post-operative blood pressure lability following CEA. Conversely, the possibility of harm cannot be excluded on the basis of the currently available data.
Anaesthesia for carotid endarterectomy
1994, Annales francaises d'anesthesie et de reanimation
Diagnostic evaluation of syncope
1991, The American Journal of Medicine
Syncope is a common medical problem and is caused by a wide variety of diseases ranging from physiologic derangements with few consequences to conditions that may be immediately life-threatening. Because of the large differential diagnosis, many diagnostic tests are available for its evaluation. However, a cause of syncope is not established in 38% to 47% of patients despite these tests. In those patients in whom a diagnosis can be assigned, the history and physical examination identify a potential cause in 49% to 85%. Furthermore, in 8% of additional patients, history and physical examination are suggestive of causes that need confirmation by specific tests. Routine blood tests rarely yield diagnostically helpful information. In those patients in whom a potential cause for syncope is identified, arrhythmias are diagnosed by electrocardiogram in 2% to 11% of patients, cardiac monitoring in 3% to 27% (telemetry or Holter), stress test in less than 1%, carotid massage in less than 1%, and electrophysiologic studies in less than 3%. Diagnosis of arrhythmias as a cause of syncope is problematic because symptomatic correlation during electrocardiographic monitoring is rarely found (approximately 4%), and as a result, there is no uniform agreement on diagnostic criteria for abnormalities. Similar problems exist in the use of electrophysiologic studies. Upright tilt testing and psychiatric examination may be useful in evaluation of recurrent syncope of unknown cause in patients without organic heart disease. Based on the results of recent studies, strategies for evaluation of patients with syncope are possible that utilize selective and goal-directed diagnostic testing.
Intraoperative local anesthetic injection of the carotid sinus nerve. A prospective, randomized study
1986, The American Journal of Surgery
One hundred patients undergoing carotid endarterectomy under general anesthesia were prospectively randomized to receive either a local anesthetic injection of their carotid sinus nerve with bupivacaine (Marcaine) or no injection. Systolic blood pressure and pulse rate were recorded before injection and at 5 and 30 minutes after injection. The need for intraoperative and postoperative use of systemic vasopressor and vasodilator medications was recorded for each group as was the incidence of arrhythmias, neurologic complications, and myocardial infarctions. Intraoperative local anesthetic injection of the carotid sinus nerve did not significantly influence the intraoperative pulse rate or incidence of hypotension. It did, however, significantly increase the incidence of intraoperative hypertension and the need for systemic vasodilator medications intraoperatively. The incidence of postoperative hypotension (6 percent of patients), hypertension (34 percent), arrhythmias (6 percent), cerebrovascular accidents (1 percent), transient ischemic attacks (3.1 percent), and myocardial infarctions (2 percent) were not significantly influenced by intraoperative local anesthetic injection of the carotid sinus nerve. Intraoperative and postoperative hypotension did not cause morbidity in this series, however, local anesthetic injection was associated with a significant incidence of perioperative hypertension. Routine prophylactic local anesthetic injection of the carotid sinus nerve cannot be recommended in view of its detrimental effects in relation to the development of hypertension.
Rationale for the use of baroceptor stimulators
1978, Journal of Surgical Research
Sustained hypertension after section of the glossopharyngeal nerve
1977, The American Journal of Medicine

View all citing articles on Scopus

^☆: This study was supported by research grants from the National Heart Institute, United States Public Health Service, HE08756 and HE06546-04(CV), and the Eli Lilly and Company, Indianapolis, Ind.

^∗: Address: Mt. Sinai Hospital, 100th St. and Fifth Ave., New York, N. Y., 10029.

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ReviewThe carotid sinus reflexes☆

Abstract

Am. Heart J.

Lancet

Lancet

Am. J. Med.

An inquiry into the symptoms and causes of the syncope angiosa commonly called angina pectoris

Experimental researches on the functions of the vagus and the cervical sympathetic nerves in man

Über mechanische Vagusreizung beim Menschen

Jenaische Ztschr. f. Med. u. Naturwiss.

Riv. clin. di Bologna.

Sur la sensibilité du coeur et des vaissaux sanguins

Arch. Ital. Biol.

The blood pressure fall produced by traction on the carotid artery

Am. J. Physiol.

Guy's Hosp. Rep.

Les effets de la compression des carotides sur la pression, sur le coeur, et sur la respiration

Arch. Ital. Biol.

Zur Frage über die zentripetalen Nerven der Arterien

Pflüger's Arch. ges. Physiol.

The carotid sinus and the cerebral circulation

Acta Psychiat. et Neurol

Reflexogenic areas of the cardiovascular system

The comparative morphology of the carotid body and carotid sinus

The carotid sinus reflex in health and disease

Medicine

Carotid sinus syncope and its bearing on the mechanism of the unconscious state and convulsions

Medicine

The circulation in experimental neurogenic hypertension

J. Clin. Invest.

Experimental hypertension produced by constriction of the carotid sinus area

Circulation Res.

Pathogenesis of experimental hypertension produced by carotid sinus area constriction in dogs

Circulation Res.

Antihypertensive effect of hypophysectomy in dogs with hypertension following bilateral carotid sinus constriction

Circulation Res.

Chronic constriction of the external and internal carotid arteries in dogs; its effect on the blood pressure

Circulation Res.

Persistent hypertension in the dog following disruption of the carotid sinus nerves and subsequent unilateral renal artery constriction

Circulation Res.

Baroceptor function in chronic renal hypertension

Circulation Res.

A new concept in the treatment of hypertension utilizing an implantable electronic device: “baropacer”

Tr. Am. Soc. Art. Int. Organs

Electronic treatment of hypertension

J.A.M.A.

Reversal of renal hypertension by electrical stimulation of the carotid sinus nerve

Surgery

Über die Reizung der Pressorezptorem im Sinus Caroticus beim Hund

Ztschr. Kreislaufforsch.

A comparison of the effects of pulsatile and nonpulsatile blood flow through the carotid sinus on the reflexogenic activity of the sinus baroreceptors in the cat

J. Physiol.

Afferent impulses in the carotid sinus nerve

J. Cell. & Comp. Physiol.

L'énervation sinu-carotidienne

Press Méd.

Syncope and convulsions due to a hyperactive carotid sinus reflex

Arch. Int. Med.

Carotid sinus nerve in man

Arch. Int. Med.

The late effects of bilateral carotid sinus denervation in man

J. Clin. Invest.

Surgery in the carotid sinus syndrome

Surgery

Observations and surgical aspects of the carotid sinus reflex

Surgery

Kreislaufuntersuchungen beim Menschen nach Resektion des Karotissinus Nerven

Deutsches Gesell. Kreislaufforsch.

The control of the function of the heart

Myocardial cathecholamines and ventricular performance during carotid artery occlusions

Am. J. Physiol.

The participation of the venomotor system in pressor reflexes

Circulation Res.

Review
The carotid sinus reflexes☆