In this issue of Heart, Parry et al1 report results of a double-blind trial of pacing in elderly recurrent fallers with carotid sinus hypersensitivity (CSH) (see page 405). The so-called PERF-CSH trial utilised a crossover design to determine whether dual-chamber cardiac pacing diminishes susceptibility to recurrent “falls” in older CSH patients.

The basis for undertaking PERF-CSH lay in the previously published SAFE-PACE study2 from the same investigators. In brief, SAFE-PACE provided two major findings. First, it offered an apparently close association between CSH and otherwise unexplained falls in older individuals. Second, SAFE-PACE provided observational evidence that cardiac pacing diminished the frequency of unexplained “falls” in this same population.2 This second observation tended to support, albeit inferentially, the concept that symptomatic CSH (ie, carotid sinus syndrome, CSS) not only was more prevalent than previously thought in older persons but also was a frequent cause of potentially harmful falls in this age group. Support for this inference was based on the fact that the apparent effectiveness of cardiac pacing in SAFE-PACE patients was consistent with the well-accepted value of pacing for ameliorating CSS symptoms, particularly transient loss of consciousness (TLOC) leading to falls and injury.3

Given the above described apparent connections among “falls” in older people, the seeming presence of CSH in older subjects, and the possibility of preventing falls by cardiac pacing, it was both logical and necessary to undertake a study that tested pacing effect directly in such patients; hence, the PERF-CSH study.1 However, despite the encouraging findings with regard to pacing prevention of falls in the original SAFE-PACE findings, the PERF-CSH report indicates that pacing offers, at best, only marginal benefit.

The clinical and economic impact of “falls” in older people is widely accepted as an important healthcare issue. For instance, …