The first step should be to attempt reduction or cessation of hypotensive medication. 2 Following this, if unsatisfactory, fludrocortisone and midodrine are the drugs Glutamate receptor cancer typically considered, but both are contraindicated in hypertensive patients. Little trial evidence is available to guide the physician. One trial, a RCT, included some vasodepressor CSS patients with a measure of success, but the trial was very small in size and without prolonged follow-up. 42 Recent discussions of the aggressiveness of blood pressure

control are relevant to these patients 43 and it is reasonable to allow higher than recommended levels of blood pressure to gain benefit at times of hypotension. A newly-available drug, droxidopa, may have some value in these patients but no evidence is yet available in CSS management. The most frequently considered drug is midodrine but one of its common side effects in males is urinary retention, making it untenable in many

who might benefit. Conclusions Carotid sinus syndrome is a relatively common cause of syncope in patients >40 years old but it is, even today, too infrequently sought as a possible cause. It occurs dominantly in males of advanced age and is diagnosed by CSM with reproduction of spontaneous symptoms. Carotid sinus hypersensitivity is a positive result of massage in the absence of clinical symptoms. Thus, these two conditions must be held as distinct entities. CSS is present in 8.8% of patients with syncope unexplained after initial evaluation, cardiac syncope is present in 10% of all patients presenting syncope and in 5% of those unexplained after initial evaluation, thus CSS is more frequent than all types of cardiac syncope combined. Cardioinhibitory

CSS is treated with acceptable success by pacing dual chamber in all those showing sinus rhythm. Greatest success may be expected in those patients who are tilt-test negative. Treatment of vasodepressor CSS is difficult and often unsatisfactory. Reduction of hypotensive medication and fluid intake increase should be the first step in management if the patient has been taking anti-hypertensive therapy. If recurrent syncope cannot be controlled, careful use of midodrine together with acceptance AV-951 of higher than usually accepted blood pressure levels is recommended. Tilt-test positive patients may have recurrence of syncope despite adequate pacing. They may benefit from measures to control the vasodepressor component of the reflex.
Base metal dental alloys are often used as alternatives to precious alloys due their cost considerations, mechanical properties, and low density.1,2 Currently, there is growing concern about nickel (Ni) being an allergen and beryllium (Be) being a toxic element.