ATLANTA — Providing a few simple muscle-tensing exercises to patients with vasovagal syncope significantly reduced their syncope recurrence rate in the randomized Physical Counterpressure Maneuver trial, Dr. Nynke van Dijk reported at the annual meeting of the American College of Cardiology.
“Physical counterpressure maneuvers should be administered as a first-line treatment in every patient presenting with vasovagal syncope and recognizable prodromal symptoms,” said Dr. van Dijk of the University of Amsterdam.
Recurrent vasovagal syncope is a common condition that patients find frightening and disruptive. It is caused by a neural reflex that reduces heart rate and lowers blood pressure by inducing vasodilation in the abdomen and legs. Until now, there has been no evidence-based treatment. Pharmacotherapy has problematic side effects, including blood pressure elevation.
Dr. van Dijk and her colleagues had previously shown in the physiology laboratory that physical counterpressure exercises were effective in preventing vasovagal syncope. They wanted to learn if this approach would be successful in real-world situations in which patients didn't have a physician by their side. The investigators randomized 223 patients with a mean of six prior episodes of vasovagal syncope and identifiable prodromal symptoms to conventional therapy alone or in combination with training in counterpressure maneuvers.
Conventional therapy consisted of an explanation of the disorder, an adjustment of lifestyle measures such as avoiding the triggers and increasing salt and water intake, and an emphasis on the importance of lying down when symptoms arise.
Training in physical counterpressure maneuvers involved a repertoire of three muscle-tensing exercises, learned in about half an hour with the aid of a blood pressure biofeedback device. The maneuvers were designed to prevent hypotension.
The three exercises were:
▸ Hand clasping with interlocking fingertips while pulling the elbows in opposite directions.
▸ Single-arm clenching while squeezing a ball or other object in the hand.
▸ The standing leg crossover, in which the thighs are firmly pushed against each other while the abdominal muscles are tightened.
Patients who initially had difficulty identifying their prodrome were helped by using tilt table testing to induce vasovagal episodes.
During 14 months of follow-up in the trial—which was sponsored by the Netherlands Heart Foundation—32% of patients in the physical counterpressure group had recurrent syncope, compared with 51% of patients in the control group. Time to first recurrence was significantly longer in the physical counterpressure group as well.
At the meeting, the Dutch study was singled out for inclusion in a high-profile, late-breaking clinical trials session by the meeting organizers, who were eager to showcase a therapeutic advance that, refreshingly, is neither high tech nor costly.
“It's an exciting study because the maneuvers don't mean giving a drug, they don't cost anything once you're trained, and they work. It's a nice thing for patients,” Dr. Steven E. Nissen, president of the American College of Cardiology, said in an interview.
“Docs should really think about this. I take care of some of these patients in my clinic and they are very difficult to manage,” added Dr. Nissen, who is also medical director of the Cleveland Clinic Cardiovascular Coordinating Center.
Moreover, Dr. Nissen, a National Aeronautics and Space Administration consultant, is thinking about teaching the physical counterpressure maneuvers to the astronauts. “Once you've been in space for 24 hours, all your blood redistributes to the central space and you urinate like crazy, so you become very volume depleted. Then when you come back to earth, you have syncope. You can't stand upright. It has some similarities to vasovagal syncope,” he said.
Clasping one's hands with interlocking fingertips while pulling the elbows in opposite directions, and clenching an arm while squeezing a ball prevents blood from pooling remotely from the brain. Sheri Mattes/Elsevier Global Medical News
