Carotid sinus massage in patients who fall: will it define the role of pacing?

In this era of diagnostic and therapeutic glitz, can a simple, safe, and universally applicable clinical maneuver—carotid sinus massage—favorably affect a clinical outcome in a large number of patients? Possibly. In this issue of the Journal, Kenny et al. (1) have evaluated patients presenting to an emergency room because of an unexplained fall. In a prospective randomized study they assessed the effect of permanent pacing in individuals who had experienced nonaccidental falls and who had a positive cardioinhibitory response (a 3-s pause) to carotid sinus massage. Insertion of a dual-chamber pacemaker with rate-drop programming resulted in a 70% reduction in the number of subsequent falls compared to nonpaced controls and a 50% reduction in syncope. Given the consequences of falls in the elderly as reviewed by the investigators—injuries