Applies to syncope and presyncope. As appeared in the December 2010 issue of Emergency Medicine Practice Guidelines Update.
Nynke van Dijk, MD, et al Journal of the American College of Cardiology
Effectiveness of Physical Counterpressure Maneuvers in Preventing Vasovagal Syncope
Vol. 48, No. 8, 2006
In this study, we assessed the effectiveness of physical counterpressure maneuvers (PCM) in daily life. 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.
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 conven- tional therapy alone, and 106 patients received conventional therapy plus training in PCM. 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. 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) (J Am Coll Cardiol 2006;48:1652-7) ? 2006 by the American College of Cardiology Foundation
2. Wolff-Parkinson-White syndrome (WPW): the most common form
of preexcitation, WPW is associated with the classic triad of
short PR interval, QRS complex widening greater than 100 milli-
seconds, and the delta wave (slurred upstroke of the QRS com-
plex). It is important to remember that delta waves, although the
most well known of the triad, are often absent in many leads.
The short PR interval is actually the most consistent finding in
all of the leads.
3. Brugada syndrome: Brugada syndrome is a purely electrical
phenomenon (meaning that patients have structurally normal hearts)
that is associated with unpredictable episodes of ventricular
tachycardia. Patients may have sudden death, but if the arrhythmia
terminates spontaneously, the patient presents instead with syncope.
The resting ECG demonstrates a right bundle branch block
morphology with STE in leads V1 to V2.
4. Hypertrophic cardiomyopathy (HCM): hypertrophic cardiomyopa-
thy may be associated with episodes of ventricular tachyarrhyth-
mias, usually associated with exertion, in relatively young patients.
The ECG manifestations of HCM are often nonspecific (high
voltage in the precordial leads, left atrial enlargement, tall R waves
in right precordial leads, and abnormal Q waves in the inferior and/
or lateral leads) . However, the combination of high voltage
with deep, narrow Q waves in the inferior and/or lateral leads is
highly specific for this entity.
5. Prolongation of the QT interval: patients with a prolonged QTc
interval are at risk for torsades de pointes. Patients are at highest risk
when the QTc interval is greater than 500 milliseconds. Major causes
of prolonged QTc interval include hypokalemia, hypocalcemia,
hypomagnesemia, hypothermia, elevated intracranial pressure, acute
cardiac ischemia, sodium channel blocking drugs, and hereditary long
Dovgalyuk Am J Emerg Med. 2007 Jul;25(6):688-701
Michelle Lin Brugada Syndrome Card:
from Edlow 2016: