Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope
Michele Brignole, MD*,*,
Francesco Croci, MD*,
Carlo Menozzi, MD ,
Alberto Solano, MD*,
Paolo Donateo, MD*,
Daniele Oddone, MD*,
Enrico Puggioni, MD* and
Gino Lolli, MD
* Arrhythmologic Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
Service of Interventional Cardiology, Department of Cardiology, Ospedale S Maria Nuova, Reggio Emilia, Italy
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Figure 1 Acute tilt-table study results. Systolic blood pressure (SBP) (A) and heart rate (HR) (B) in the active treatment arm (continuous line) and control arm (dotted line). Values are expressed as mean ± 1 SE. During the test, some patients had syncope and the test was interrupted; numbers at the top refer to patients free of syncope at that time. (A) Handgrip (HG) started at the onset of impending syncope; compared with placebo, active HG caused a significant increase in SBP, which was already significant after 10 s. (B) Heart rate behavior was similar in the two arms. There was an initial compensatory HR increase, which peaked at the time of impending syncope. *p < 0.05.
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Figure 2 A case of handgrip (HG) tilting. The top trace shows the heart rate (HR) curve; the bottom trace shows systolic, diastolic, and mean blood pressure (BP) curves. Symptoms of impending syncope occurred when systolic BP fell to 80 mm Hg with an abrupt drop in HR from 95 beats/min to 65 beats/min. During treatment, BP progressively increased and symptoms disappeared. The vagal bradycardic reflex was also quickly interrupted, and HR rose in an oscillatory manner to baseline values. During the recovery phase, systolic BP decreased but remained at values higher than before and symptoms did not recur.
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Figure 3 A case of control and active handgrip (HG) tilting in the same patient. The top trace shows the heart rate (HR) curve; the bottom trace shows systolic, diastolic, and mean blood pressure (BP) curves. Right panel, control. The pattern was that of a typical tilt-induced vasovagal reaction, with hypotension and bradycardia. The arrow indicates the time of onset of symptoms of impending syncope, when placebo HG was administered. Subsequently, BP and HR continued to fall and the patient suffered syncope after 45 s. Left panel, active treatment. Initially, the pattern of BP and HR was similar to that observed in the control study. The start of HG caused a rapid rise in BP, which persisted as long as the contraction was maintained; initially, HR slightly increased and then slightly decreased; symptoms disappeared. During the recovery phase, SBP fell again to 90 mm Hg and symptoms reappeared.
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Figure 4 Cardiovascular response to handgrip and arm-tensing in healthy subjects. A progressive and similar rise in systolic blood pressure (SBP) was recorded, with a rapid decline toward baseline values at the end of the maneuvers. Heart rate (HR) also rose during the contraction, whereas in the syncope patients it fell.
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