© 2004 by European Society of Cardiology
Efficacy and feasibility of isometric arm counter-pressure manoeuvres to abort impending vasovagal syncope during real life
aArrhythmologic Centre, Department of Cardiology Ospedali del Tigullio, Via don Bobbio, 16033 Lavagna, Italy; bService of Interventional Cardiology, Department of Cardiology Ospedale S Maria Nuova, Reggio Emilia, Italy
Manuscript submitted 22 December 2003. Accepted after revision 28 March 2004.
*Corresponding author. Fax: +39-0185-306506. E-mail address: mbrignole{at}asl4.liguria.it
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Abstract |
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AIMS: Isometric arm exercises are able to increase blood pressure during the phase of impending vasovagal syncope. We evaluated their efficacy and feasibility during daily life in a group of 29 consecutive patients affected by vasovagal syncopes.
METHODS: The patients were trained to use arm tensing and/or handgrip in case of occurrence of symptoms of impending syncope.
RESULTS: During 14±6 months of follow-up, 260 episodes of impending syncope were reported by 19 patients; the manoeuvres were self-administered by these patients in 98% of cases and were able to abort syncope in 99.6% of cases. Overall, 5 episodes of syncope occurred in 5 patients (17%), in 4 cases without and in 1 with activation of the manoeuvres. Syncope recurred in 4 (40%) of 10 patients aged >65 years versus only 1 (5%) of 19 patients aged 
65 years, p=0.03. The non-responders had more episodes of impending syncope than responders (37±32 vs 3±4, p=0.001). Among 19 clinical variables, age in years was the only significant predictor of syncopal recurrence. No patients had injury or other adverse morbidity related to the relapses.
CONCLUSIONS: Isometric arm counter-pressure manoeuvres are able to abort impending vasovagal syncope in most patients aged 65 years. Arm counter-pressure manoeuvres are feasible, safe and well accepted by the patients in the daily life.
Key Words: syncope, autonomic nervous system, tilt test, isometric exercise, handgrip
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Introduction |
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Non-pharmacological "physical" treatments are arising as a new first choice treatment of vasovagal syncope.
In highly motivated patients with recurrent vasovagal symptoms, the prescription of progressively prolonged periods of enforced upright posture (so-called ‘tilt-training’) has reduced syncope recurrence in 3 non-randomized studies [1–
3]. This preventive treatment is hampered by the low compliance of the patients to continue the training programme for a long period.
When symptoms of impending syncope occur, isometric arm and leg counter-pressure manoeuvres [4,5] have been recently shown to be able to abort the vasovagal reaction induced during tilt test during the prodromal phase by increasing blood pressure. During the prodromal phase, blood pressure falls markedly; this fall usually precedes the decrease in heart rate, which may be absent at least at the beginning of this phase [6,7]. Hypotension is caused by vasodilatation in the skeletal muscles due to inhibition of sympathetic vasoconstrictive activity [6,8–11]. Isometric manoeuvres are able to induce a significant blood pressure increase during the phase of impending vasovagal syncope and allow the patient to avoid or delay losing consciousness in most cases. This effect seems to be mediated largely by sympathetic nerve discharge and vascular resistance increase during manoeuvres and to mechanical compression of the venous vascular bed in the legs and abdomen [4]. In the acute tilt study [4], handgrip caused an abrupt rise in systemic blood pressure, which was already evident after 10 s. Consequently, symptoms of impending syncope disappeared in many patients and remained unchanged in others, and syncope was aborted. Conversely, in the control arm, blood pressure continued to fall slightly and about half of the patients developed syncope after a mean of 66 s. The benefits were maintained during the recovery phase, and only 20% of patients ultimately developed syncope (versus 58% in the control arm). This finding means that isometric arm contraction is able to abort syncope in most cases, even when the patient remains in the standing position. The practical consequence is that when symptoms of impending syncope occur, the patient will have enough time to apply the counter-pressure treatment before losing consciousness; in some cases the treatment will definitely abort the vasovagal reaction, in others it will able to delay syncope for the duration of the manoeuvre, thus allowing enough time to initiate other manoeuvres to abort syncope (e.g. supine posture).
This approach needs to be verified in real life. The aim of the study was to evaluate the efficacy and feasibility of isometric arm counter-pressure manoeuvres to abort impending vasovagal syncope during daily life in a group of consecutive patients.
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Methods |
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The study enroled consecutive patients affected by vasovagal syncope who had: a history of 3 syncopal episodes in the last 2 years or at least 1 syncopal spell in the last year and at least 3 episodes of presyncope in the last year; syncopal episode(s) preceded by prodromal symptoms that were recognized by the patient as symptoms of impending syncope; syncope reproduced during tilt tests; an age
18 years. Impending syncope was defined as the onset of one or more of the following symptoms: weakness, dizziness, abdominal discomfort, nausea, sweating, sighing, and blurred vision, associated with hypotension (if documented).
The Italian tilt protocol [12], namely 60° passive tilting followed by 0.4 mg nitroglycerin challenge when the passive phase fails to induce syncope, was used. Continuous recording of ECG tracing and noninvasive beat-to-beat arterial blood pressure was performed by means of the Finapres method [13]. The New VASIS classification was used to stratify positive responses [7]. During the tilt test the patients were advised how to recognize symptoms of impending syncope and the values of blood pressure and heart rate at the time of impending syncope were recorded.
Instruction counter-pressure manoeuvres
The patients were trained to use arm tensing and/or handgrip in case of occurrence of symptoms of impending syncope. Arm tensing consists of the maximum tolerated isometric contraction of the two arms achieved by gripping one hand with the other and contemporarily abducting (pushing away) the arms for the maximum tolerated time or till complete disappearance of symptoms (Fig. 1). Handgrip consists of the maximal voluntary contraction of a rubber ball (approximately of 5–6 cm diameter) taken in the dominant hand for the maximum tolerated time or till complete disappearance of symptoms (Fig. 2). Patients were instructed to maintain the manoeuvre they chose as long as possible and eventually move on to the second manoeuvre if useful. A session protocol (maximum duration of 1 h) consisted of: explanation of purpose and session-programme; explanation of simple physiology and vasovagal reflexes; demonstration and explanation of the 2 manoeuvres; practising of the 2 manoeuvres using Finapres-blood pressure recordings and electrocardiographic monitoring as biofeedback signal. Furthermore, an instruction sheet with photographs was offered to the patients.
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Follow-up
All patients were trained to perform the arm isometric manoeuvres and were discharged with the recommendation to self-administer it at the maximum tolerated voluntary contraction as soon as symptoms of impending syncope identical to those reported by the patients prior to treatment occurred, and until symptoms were aborted. Thereafter, the patients were seen every 3 months in the outpatient clinic by one of the investigators. During those visits, the patients were asked about the number of episodes of syncope and impending syncope and the number of self-administered counter-pressure manoeuvres performed to abort them. They were also asked to fill in a semi-quantitative questionnaire on their satisfaction with the treatment (1 = very satisfied; 2 = moderately satisfied; 3 = partially satisfied; 4 = unsatisfied).
Statistical methods
Intrapatient comparison was carried out by means of two-tailed paired Student's t test or non-parametric test U of Mann–Whitney for continuous variables as appropriate and by means of McNemar test for proportions. The time to the onset of the syncope was analyzed by means of Kaplan–Meier survival curves, which were compared by means of the log-rank test.
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Results |
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From August 2001 to December 2002, 144 patients had a tilt-induced vasovagal syncope, 34 were eligible and 29 of these were enroled (Fig. 3). Reasons for non-inclusion were no need for treatment (rare and not severe symptoms), inconstant or uncertain prodromal symptoms, patients chose not to enter the trial or did not seem likely to be compliant. The characteristics of the patients are shown in the Table 1.
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During the follow-up of 14±6 months (range 6–21), 260 episodes of impending syncope were reported by 19 patients (median 4, interquartile range 3–13); counter-pressure manoeuvres were self-administered by these patients in 98% of cases and were able to abort syncope in 99.6% of cases. Overall, 5 episodes of syncope occurred in 5 patients (17%): in 4 cases the patients were unable to start manoeuvres because of the sudden onset of syncope, in 1 case the patient activated the manoeuvres but they were ineffective (Fig. 3). The non-responders had more episodes of impending syncope than responders (37±32 vs 3±4, p=0.001); overall, in non-responders the counter-pressure manoeuvres were self-administered 183 times implying syncope occurrence in 3% of the episodes. The actuarial recurrence rate of syncope was 19% (95% standard error, ±7%) at 1 year. Arm tensing was preferred as first manoeuvre by 12 patients, handgrip by 7 patients.
Syncope recurred in 4 (40%) of 10 patients aged >65 years versus only 1 (5%) of 19 patients aged 65 years, p=0.03. The actuarial predicted recurrence rate of syncope at 1 year was 44% (95% standard error, ±16%) and 5% (95% standard error, ±5%) in patients aged >65 years and 65 years, respectively (Fig. 4). Among the 19 variables reported in Table 1, age >65 years was the only significant predictor of syncopal recurrence. The only predictor of use of the manoeuvres was the number of syncopes before enrolment (median 6 in those who activated versus 2 in those who did not, p=0.006).
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No patients had injury or other adverse morbidity related to the relapses. Patient satisfaction was very high among the 19 who activated the manoeuvres during follow-up: 63% of patients were very satisfied with the treatment and 37% moderately satisfied.
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Discussion |
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The main result of the study is that chronic treatment based on self-administered arm counter-pressure manoeuvres is feasible, safe and well accepted by the patient. The treatment does not seem to be efficacious in older patients. Arm counter-pressure manoeuvres can be proposed as a new first-line treatment for those patients who are able to recognize prodromal symptoms before vasovagal syncope and are less than 65 years old.
Vasovagal syncope is preceded by prodromal symptoms in about two thirds of cases [14]. Prodromal symptoms are present in virtually all cases of tilt-induced vasovagal syncope, which occurs, on average, 1 min after the onset of prodromal symptoms [4–6]. Thus, counter-pressure manoeuvres are justified to be applied to vasovagal patients below the age of 65 years provided they have sufficiently severe recurrent recognizable symptoms. Owing to the small population, however, an exact cut-off age limit cannot be defined and the age limit of 65 years should be considered only indicative. There are several possible explanations, not yet investigated, for the failure of the manoeuvres in the older patients: the need of more forceful intervention, the frequent association with other autonomic disturbances, i.e, orthostatic hypotension and post-prandial hypotension, the diminished muscle strength and rapidity to react to the impending symptoms, etc. Moreover, the number of patients involved was relatively small and the number of episodes of impending syncope high in the elderly. Thus, the conclusion regarding inefficacy of the manoeuvres in the elderly should be considered with caution.
Apart from age, no other variable, among the 19 we analyzed and that are reported in Table 1, was able to predict a different outcome. For instance, no patient who had a cardioinhibitory response during the index tilt test had syncope during the follow-up; also the number of syncopal episodes in the history or their clinical features were unrelated to outcome. However, the numbers are small and failure to detect a significant difference between responders and non-responders may well be type II error.
How efficacious are counter-pressure manoeuvres?
This approach seems to be very helpful in real life. It is applicable in about two thirds of the vasovagal patients younger than 65 years who have prodromal symptoms before syncope. During follow-up, these patients will be able to enact a counter-pressure manoeuvre and consequently relieve symptoms in vast majority of cases. The treatment is therefore easy to perform, reliable, safe and well accepted by the patients, who expressed a good level of satisfaction. Admittedly, most of these episodes would have resolved spontaneously without leading to syncope, even in the absence of the counter-pressure treatment. Owing to the open design of the follow-up study, we are unable to establish the exact benefit of the treatment. Furthermore, some placebo effect is likely to be present. A randomized trial should address this question. In any case, the physical manoeuvres seem to be particularly helpful in patients aged 65 years as these patients showed, at 14 months, only a 5% recurrence rate (95% standard error between 0% and 10%). This figure is by far lower than that generally reported in the literature for vasovagal patients with similar characteristics. For example, in untreated patients with a history of 3 syncopal episodes, Sheldon and Rose [15] predicted a 40% recurrence rate at 1 year and in 2 randomized placebo-controlled studies [16,17], the recurrence rate in the placebo arm was 24% and 46% at 1 year. Conversely, the usefulness of this treatment is questionable in older patients who showed a recurrence rate similar to that in the above literature.
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References |
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