Effectiveness of Physical Counterpressure Maneuvers in Preventing Vasovagal Syncope
Open accessAbstract
Objectives In this study, we assessed the effectiveness of physical counterpressure maneuvers (PCM) in daily life.Background There is presently no evidence-based therapy for vasovagal syncope. Current treatment consists of explanation and life-style advice. Physical counterpressure maneuvers have been shown to raise blood pressure and to control or abort vasovagal episodes in laboratory conditions.Methods We performed a multicenter, prospective, randomized clinical trial, which included 223 patients age 38.6 (+/-15.4) years with recurrent vasovagal syncope and recognizable prodromal symptoms. One hundred and seventeen patients were randomized to standardized conventional therapy alone, and 106 patients received conventional therapy plus training in PCM.Results The median yearly syncope burden during follow-up was significantly lower in the group trained in PCM than in the control group (p = 0.004). During a mean follow-up period of 14 months, overall 50.9% of the patients with conventional treatment and 31.6% of the patients trained in PCM experienced a syncopal recurrence (p = 0.005). Actuarial recurrence-free survival was better in the treatment group (log-rank p = 0.018), resulting in a relative risk reduction of 39% (95% confidence interval, 11% to 53%). No adverse events were reported.Conclusions Physical counterpressure maneuvers are a risk-free, effective, and low-cost treatment method in patients with vasovagal syncope and recognizable prodromal symptoms, and should be advised as first-line treatment in patients presenting with vasovagal syncope with prodromal symptoms. (The PC-Trial; http://www.controlled-trials.com/isrctn/trial/45146526/0/45146526.html; ISRCTN45146526).
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In that trial, syncope recurred in a substantial minority of patients, and the study was open label.
“However, syncope recurred in a substantial minority of patients, and the study was open label.”
From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [120]
The Population section reports syncope recurrence in 31 of 98 patients (31.6%) in the maneuver group and 56 of 110 (50.9%) in the conventional-treatment group, supporting ‘a substantial minority.’ The Study limitations section says patients were blinded to the randomization outcome, while physicians were not; describing the study without qualification as open label overlooks that patient blinding. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIn a randomized prospective parallel clinical trial, a physical counterpressure maneuver was superior to controls, with a relative risk reduction of 39%.
“In a randomized, prospective parallel clinical trial, a physical counterpressure maneuver was superior to controls, with a relative risk reduction of 39%.120”
From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [120]
The Methods describe a prospective randomized trial, and the Results (Population section) report fewer syncopal recurrences with physical counterpressure maneuvers than with conventional therapy. However, that Results passage gives a relative risk reduction of 0.36 (36%), not the claimed 39%. (LLM, conf=0.86)
Experimental — accuracy not yet measuredTilt testing is widely accepted as a useful tool to demonstrate susceptibility of the patient to reflex syncope, especially a hypotensive (vasodepressive) tendency, and thereby to initiate treatment.
“However, tilt testing is widely accepted as a useful tool to demonstrate susceptibility of the patient to reflex syncope, especially a hypotensive (vasodepressive) tendency, and thereby to initiate treatment (e.g. physical manoeuvres, see section 5). 119-121”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [121]
The Study population section (page not provided) says tilt-table testing was used to confirm or establish a vasovagal syncope diagnosis, and that a positive response could include hypotension. It does not establish that tilt testing is widely accepted specifically to identify a vasodepressive tendency and thereby initiate treatment with physical manoeuvres. (LLM, conf=0.82)
Experimental — accuracy not yet measuredIn the Physical Counterpressure Manoeuvres Trial, PCM training improved actuarial recurrence-free survival (log-rank P=0.018), resulting in a relative risk reduction of 39% (95% CI 11-53).
“Actuarial recurrence-free survival was better in the PCM group (log-rank P =0.018), resulting in a relative risk reduction of 39% (95% CI 11-53).”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [121]
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- Authors
- van Dijk, N., Quartieri, F., Blanc, J.-J., Garcia-Civera, R., Brignole, M., Moya, A., & Wieling, W.
- Affiliations
- Santa Maria Nuova Hospital (IT)
- Presidio Ospedaliero (IT)
- Amsterdam UMC Location University of Amsterdam (NL)
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2006-10
- Volume
- 48
- Issue
- 8
- Pages
- 1652-1657
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2165000248
- Semantic Scholar
- 30ef331168f49daba10acad610b8d1c9f2393586
- Cited by
- 315
- References
- 30
- Citations by year
- 2026: 8 · 2025: 12 · 2024: 8 · 2023: 9 · 2022: 11 · 2021: 21 · 2020: 17 · 2019: 14 · 2018: 11 · 2017: 19 · 2016: 18 · 2015: 13 · 2014: 22 · 2013: 21 · 2012: 19
- FWCI
- 16.66
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Pure Amsterdam UMC (submittedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Life Sciences › Neuroscience › Neurology › Vestibular and auditory disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- vasovagal syncope, syncope prevention, recurrent syncope, prodromal symptoms, recurrence-free survival, first-line therapy
- MeSH terms
- Actuarial Analysis, Adolescent, Adult, Aged, Arm, Hand, Hemodynamics, Humans, Leg, Middle Aged, Motor Activity, Pressure, Survival Analysis, Treatment Outcome, Syncope, Vasovagal
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