title: Physical counter-pressure manoeuvres in preventing syncopal recurrence in patients older than 40 years with recurrent neurally mediated syncope: a controlled study from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3)†.
abstract: OBJECTIVE
  Physical counter-pressure manoeuvres (PCM) are effective in young patients with vasovagal syncope and recognizable prodromal symptoms. The aim of this study was to investigate their effectiveness in patients ≥40 years with severe neurally mediated syncope (NMS) enroled in the Third International Study on Syncope of Uncertain Etiology (ISSUE-3).
  
  
  RESULTS
  In the ISSUE-3 study, 63 out of 162 patients had a diagnosis of hypotensive NMS (Types 2, 3, and 4A) documented by implantable loop recorder; of these, 40 were instructed to perform isometric leg and arm PCM therapy. Their mean age was 62 ± 13 years; 47% of patients had a history of some episodes without prodrome. A group of 45 untreated patients acted as controls. The primary endpoint was the time to first syncope recurrence. During follow-up, syncope recurred in 15 PCM patients (37%) and in 24 control patients (53%) (P = 0.14). At 21 months, the modelled syncope recurrence rates were 42% [95% confidence interval (CI): 27-61] and 64% (95% CI: 48-80), respectively (P = 0.27).
  
  
  CONCLUSIONS
  In conclusion, many ISSUE-3 patients affected by hypotensive NMS have syncopal recurrence despite PCM. Older age and the absence of sufficiently long recognizable prodromal symptoms in the ISSUE-3 population might have hampered the effectiveness of PC therapy.
authors.affiliation: Department of Cardiology, Ospedale di Bolzano, Via Boelher, 5, 39100 Bolzano, Italy marco.tomaino@asbz.it.
authors.forename: Marco
authors.initials: M
authors.lastname: Tomaino
authors.affiliation: Department of Cardiology, Ospedale di Bolzano, Via Boelher, 5, 39100 Bolzano, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Romeo
authors.affiliation: Department of Cardiology, Ospedale SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Vitale
authors.affiliation: Department of Cardiology, Hospital du Sacre-Coeur de Montreal, 5400 Montreal, Canada.
authors.forename: Teresa
authors.initials: T
authors.lastname: Kus
authors.affiliation: Department of Cardiology, Hospital Universitario Vall d'Hebron, 08035 Barcelona, Spain.
authors.forename: Angel
authors.initials: A
authors.lastname: Moya
authors.affiliation: Department of Cardiology, Academisch Medisch Centrum, 1105 Amsterdam, The Netherlands.
authors.forename: Nynke
authors.initials: N
authors.lastname: van Dijk
authors.affiliation: EMEA Regional Clinical Center, Medtronic Clinical Research Institute, 00165 Rome, Italy.
authors.forename: Silvia
authors.initials: S
authors.lastname: Giuli
authors.affiliation: Medtronic Italia, 00165 Rome, Italy.
authors.forename: Giorgia
authors.initials: G
authors.lastname: D'Ippolito
authors.affiliation: EMEA Regional Clinical Center, Medtronic Clinical Research Institute, 00165 Rome, Italy.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Gentili
authors.affiliation: Department of Cardiology, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London W21NY, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Sutton
mesh_terms: D000368:Aged; D001132:Arm / Q000502:physiology*; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D007866:Leg / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D009043:Motor Activity / Q000502:physiology*; D012008:Recurrence; D019462:Syncope, Vasovagal / Q000503:physiopathology / Q000517:prevention & control*; D016896:Treatment Outcome
keywords: Neurally mediated syncope; Old patients; Physical counter-pressure manoeuvres