Journal of the American College of Cardiology Vol. 40, No.

11, 2002
© 2002 by the American College of Cardiology Foundation ISSN 0735-1097/02/$22.00
Published by Elsevier Science Inc. PII S0735-1097(02)02683-9

EXPEDITED REVIEW

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,* Gino Lolli, MD†
Lavagna and Reggio Emilia, Italy
OBJECTIVES We hypothesized that isometric arm exercises were able to increase blood pressure (BP)
during the phase of impending vasovagal syncope and allow the patient to avoid losing
consciousness.
BACKGROUND Hypotension is always present during the prodromal phase of vasovagal syncope.
METHODS We evaluated the effect of handgrip (HG) and arm-tensing in 19 patients affected by
tilt-induced vasovagal syncope. The study consisted of an acute single-blind, placebo-
controlled, randomized, cross-over tilt-table efficacy study and a clinical follow-up feasibility
study.
RESULTS In the acute tilt study, HG was administered for 2 min, starting at the time of onset of
symptoms of impending syncope. In the active arm, HG caused an increase in systolic blood
pressure (SBP) from 92 ⫾ 10 mm Hg to 105 ⫾ 38 mm Hg, whereas in the placebo arm SBP
decreased from 91 ⫾ 11 mm Hg to 73 ⫾ 21 mm Hg (p ⫽ 0.008). Heart rate behavior was
similar in the two arms. In the active arm, 63% of patients became asymptomatic, versus 11%
in the control arm (p ⫽ 0.02); conversely, only 5% of patients developed syncope, versus 47%
in the control arm (p ⫽ 0.01). The patients were trained to self-administer arm-tensing
treatment as soon as symptoms of impending syncope occurred. During 9 ⫾ 3 months of
follow-up, the treatment was actually performed in 95/97 episodes of impending syncope
(98%) and was successful in 94/95 (99%). No patients suffered injury or other adverse
morbidity related to the relapses.
CONCLUSIONS Isometric arm contraction is able to abort impending vasovagal syncope by increasing systemic
BP. Arm counter-pressure maneuvers can be proposed as a new, feasible, safe, and well
accepted first-line treatment for vasovagal syncope. (J Am Coll Cardiol 2002;40:2053–9)
© 2002 by the American College of Cardiology Foundation

Vasovagal syncope is preceded by prodromal symptoms in METHODS

about two-thirds of cases (1). Prodromal symptoms are
The study enrolled patients affected by vasovagal syncope
present in virtually all cases of tilt-induced vasovagal syn-
and consisted of an acute tilt-table efficacy study and a
cope, which occurs, on average, 1 min after the onset of
clinical follow-up feasibility study. In addition, the physio-
prodromal symptoms (2). During the prodromal phase,
logical cardiovascular response to two isometric arm exer-
blood pressure (BP) falls markedly; this fall usually precedes
cises was evaluated in healthy subjects.
the decrease in heart rate (HR), which may be absent at least
We studied patients affected by vasovagal syncope who
at the beginning of this phase (2,3). Hypotension is caused
had the following: a history of ⱖ1 episode of syncope; one
by vasodilation in the skeletal muscles due to inhibition of
or more syncopal episodes preceded by prodromal symp-
sympathetic vasoconstrictive activity (2–7). In normal and
toms that were recognized by the patient as symptoms of
hypertensive subjects, isometric handgrip (HG) exercises are
impending syncope; syncope reproduced during two tilt
able to induce a significant BP increase, which is mediated
tests performed on different days; age ⱖ18 years.
largely by endogenous catecholamine release (8,9). Muscle
During the second baseline tilt test, the patients were
sympathetic nerve discharge and vascular resistance increase
instructed to recognize the onset of prodromal symptoms.
during HG in healthy subjects (10). We hypothesized that
The Italian tilt protocol (11), namely 60° passive tilting
isometric arm exercises were able to increase BP during the
followed by 0.4 mg nitroglycerine challenge when the
phase of impending vasovagal syncope and allow the patient
passive phase fails to induce syncope, was used for this test
to avoid losing consciousness.
and for those of the acute study. Continuous recording of
electrocardiogram (ECG) tracing and noninvasive beat-to-
From the *Arrhythmologic Centre, Department of Cardiology, Ospedali del beat arterial BP was performed by means of the Finapres
Tigullio, Lavagna, Italy; and †Service of Interventional Cardiology, Department of method (12). The average value of six consecutive beats was
Cardiology, Ospedale S Maria Nuova, Reggio Emilia, Italy.
Manuscript received September 11, 2002; revised manuscript received October 7,
considered for analysis. The new VASIS classification was
2002, accepted October 10, 2002. used to stratify positive responses (3).
2054 Brignole et al.
Counter-Maneuvers Against Vasovagal Syncope
Abbreviations and Acronyms
BP ⫽ blood pressure
DBP ⫽ diastolic blood pressure
ECG ⫽ electrocardiogram
HG ⫽ handgrip
HR ⫽ heart rate
SBP ⫽ systolic blood pressure
Acute tilt-table study. The acute tilt study was a single-
blind, placebo-controlled, randomized, cross-over study
which was designed to evaluate the ability of HG to abort
vasovagal syncope induced during tilt testing. The patients
underwent two tilt tests, at least 1 h apart, on the same day.
During one test, active HG treatment (using a Vigorimeter
Martin cuff manometer, according to the standard protocol)
(8,9) was administered for 2 min at 50% of maximal
voluntary contraction. During the other test, the placebo
HG treatment was administered for 2 min without contrac-
tion. The sequential order of the treatments was random-
ized. In both cases, treatment was started at the time of
onset of symptoms of impending syncope, while the patient
was standing on the tilt table. The treatment—and the
test—was interrupted in the event of syncope occurrence. If
syncope did not occur, the patient was tilted for a further 2
min after the end of treatment (recovery phase). Again, the
recovery phase—and the test—was interrupted in the event
of syncope occurrence.
Impending syncope was defined as the onset of one or
more of the following symptoms: weakness, dizziness,
abdominal discomfort, nausea, sweating, sighing, and
blurred vision, associated with marked systolic blood pres-
sure (SBP) drop.
Cardiovascular response to HG and arm-tensing in
healthy subjects. In 32 healthy volunteers (mean age 44 ⫾
12, 16 males), we evaluated the physiological response to 2
min of isometric contraction during standard HG (as
described earlier) and during arm-muscle tensing exercise.
Arm-tensing consisted of the maximum tolerated isometric
contraction of the two arms achieved by gripping one hand
with the other and contemporarily abducting (pushing
away) the arms. The tests were performed on a tilt table at
60°; ECG tracing and noninvasive beat-to-beat arterial BP
were continuously recorded. The sequential order of the
maneuvers was randomized.
This study had two aims: to evaluate the cardiovascular
response during HG tilting in healthy subjects and to
compare HG with arm-tensing. Indeed, because arm-
tensing does not require the use of any equipment, it seems
more suitable, in that it can be performed during daily life
to abort spontaneous attacks.
Follow-up. Irrespective of the results of the acute tilt
phase, all patients were trained to perform the arm-tensing
maneuver and were discharged with the recommendation to
self-administer it at the maximum tolerated voluntary con-
traction as soon as symptoms of impending syncope iden-
JACC Vol. 40, No. 11, 2002
December 4, 2002:2053–9
Table 1. Characteristics of the Patients
Number of patients 19
Mean age, yrs 55 ⫾ 20
Males 12 (63%)
History of syncope
Median number of syncopes (interquartile range) 3 (1–11)
Duration (interquartile range), yrs 3 (1–10)
Typical vasovagal/situational triggers 7 (37%)
Postprandial 2 (11%)
Secondary trauma 4 (21%)
Number of patients with pre-syncope 11 (58%)
Associated conditions
Hypertension 3 (16%)
Cardiac abnormalities 3 (16%)
Vasoactive therapy 5 (26%)
Baseline tilt-test responses (during repeat tilt)
Positive during passive/nitroglycerin phase 2/17
Cardioinhibitory, mixed, vasodepressor type 5/12/2
Classic/dysautonomic hemodynamic pattern 12/7
Systolic blood pressure at time of impending 88 ⫾ 9
syncope, mm Hg
Heart rate at time of impending syncope, 82 ⫾ 21
beats/min
tical to those reported by the patients before treatment
occurred, and until symptoms were aborted. Thereafter, the
patients were seen every three months in the out-patient
clinic by one of the investigators. During those visits, the
patients were asked about the number of episodes of
syncope and impending syncope and the number of self-
administered counter-pressure maneuvers performed to
abort them. They were also asked fill in a semi-quantitative
questionnaire on their satisfaction with the treatment (1 ⫽
very satisfied; 2 ⫽ moderately satisfied; 3 ⫽ partially
satisfied; 4 ⫽ unsatisfied).
Statistical methods. Intrapatient comparison was carried
out by means of two-tailed paired Student t test for
continuous variables and the McNemar test for proportions.
RESULTS
From August 2001 to April 2002, 93 patients had a
tilt-induced vasovagal syncope, and 23 of these were en-
rolled. Reasons for non-inclusion were as follows: no repro-
ducible tilt response, no need for treatment, inconstant or
uncertain prodromal symptoms, patients chose not to enter
the trial or did not seem likely to be compliant. During the
acute tilt-table study, neither active treatment nor control
treatment was able to be started in three patients owing to
the lack of reproducibility of tilt test (non-induction of
impending syncope); in another patient, the control treat-
ment could not be started for the same reason. Thus, 19
patients were able to test both active and control treatments.
These were evaluated and their results were analyzed
(Table 1).
Acute tilt-table study results. The results are shown in
Table 2 and Figure 1. Symptoms of impending syncope
occurred when SBP dropped by 43 ⫾ 9 and 42 ⫾ 9 mm Hg
to an absolute value of 92 ⫾ 10 and 91 ⫾ 11 mm Hg,
JACC Vol. 40, No. 11, 2002 Brignole et al. 2055
December 4, 2002:2053–9 Counter-Maneuvers Against Vasovagal Syncope

Table 2. Effects of Counter-Pressure Maneuvers During Tilt Testing in the 19 Evaluable

Patients With Syncope
Active Control p Value
Beginning of tilt test
Systolic blood pressure, mm Hg 134 ⫾ 20 132 ⫾ 20
Diastolic blood pressure, mm Hg 75 ⫾ 14 73 ⫾ 11
Heart rate, beats/min 72 ⫾ 9 70 ⫾ 11
Impending syncope
Systolic blood pressure, mm Hg 92 ⫾ 10 91 ⫾ 11
Diastolic blood pressure, mm Hg 61 ⫾ 15 63 ⫾ 10
Heart rate, beats/min 90 ⫾ 25 84 ⫾ 15
End of counter-pressure phase*
Systolic blood pressure, mm Hg 105 ⫾ 38 73 ⫾ 21 0.008
Diastolic blood pressure, mm Hg 71 ⫾ 24 51 ⫾ 20 0.004
Heart rate, beats/min 85 ⫾ 25 77 ⫾ 20
Symptoms
Syncope 1 (5%) 9 (47%) 0.01
Unchanged from baseline 6 (32%) 6 (32%)
Nausea/headache 0 (0%) 2 (11%)
None 12 (63%) 2 (11%) 0.02
Recovery phase
Symptoms
Syncope 3/18 (17%) 2/10 (20%)
Unchanged from baseline 7/18 (33%) 4/10 (40%)
Nausea/headache 0/18 (0%) 2/10 (20%)
None 9/19 (50%) 2/10 (20%)
Total positive responses (syncope), patients 4 (21%) 11 (58%) 0.02
*120 s or until syncope occurrence.

respectively, in the two arms. At that time, treatment was
undertaken for 2 min or until syncope occurred. In the
active arm, BP rose very quickly, then stabilized, whereas in
the control arm BP continued to fall; the difference was
significant. Heart rate decreased to the same extent in the
two arms. Figures 2 and 3 show two illustrative cases. In the
active arm, 12 (63%) patients became asymptomatic versus
only 2 (11%) in the control arm (p ⫽ 0.02); conversely, only
1 patient (5%) developed syncope (after 70 s) in the active
arm, whereas 9 (47%) patients developed syncope in the
control arm (after 66 ⫾ 36 s) (p ⫽ 0.01). During the
recovery phase, syncope occurred in 3 and 2 patients,
respectively. Overall, four patients had syncope induced
during both active and control studies and seven had
syncope induced during the control study but not during the
active study (21% vs. 58%, p ⫽ 0.02).
Cardiovascular response to HG and arm-tensing in
healthy subjects. In healthy subjects SBP, diastolic blood
pressure (DBP), and HR increased to a similar extent
during HG and arm-tensing (Fig. 4). Indeed, SBP in-
creased from 125 ⫾ 18 mm Hg to 156 ⫾ 26 mm Hg during
HG and from 123 ⫾ 15 mm Hg to 155 ⫾ 24 during
arm-tensing; DBP increased from 72 ⫾ 10 mm Hg to 94 ⫾
16 mm Hg during HG and from 73 ⫾ 11 mm Hg to 97 ⫾
17 mm Hg during arm-tensing; HR increased from 76 ⫾ 14
beats/min to 84 ⫾ 16 during HG and from 75 ⫾ 13 to 86
⫾ 15 during arm-tensing.
The maximum increase in SBP was ⫹31 ⫾ 16 mm Hg
during HG and ⫹32 ⫾ 18 mm Hg during arm-tensing;
these values were only slightly higher than the maximum
increase observed in the active arm of the syncope patients,
which was ⫹29 ⫾ 41 mm Hg (not statistically different).
On the contrary, HR behavior showed opposite patterns,
increasing in healthy subjects (⫹9 ⫾ 11 beats/min and ⫹11
⫾ 11 beats/min during HG and arm-tensing, respectively)
and decreasing in syncope patients (-8 ⫾ 17 beats/min); this
difference was highly significant (p ⫽ 0.000)
Follow-up. Follow-up data on 18 patients are available.
During a mean follow-up of 9 ⫾ 3 months, 11 patients
experienced a total of 97 symptoms of impending syncope
(median 3, interquartile range 2 to 5.5). The patients were
able to self-administer the treatment 95/97 times (98%); on
two occasions two patients had a syncopal relapse but were
unable to perform the maneuver. The treatment was suc-
cessful 94/95 times (99%); in one case syncope developed
despite treatment. No patients had injury or other adverse
morbidity related to the relapses. Patient satisfaction was
very good: 64% of the patients were very satisfied with the
treatment and 36% were moderately satisfied.
DISCUSSION
This study shows that isometric arm contraction is able to
abort impending vasovagal syncope by increasing systemic
BP. Long-term treatment based on self-administered arm
counter-pressure maneuvers is feasible, safe, and well ac-
cepted by the patient. Arm counter-pressure maneuvers can
be proposed as a new first-line treatment for those patients
who are able to recognize prodromal symptoms before
vasovagal syncope.
2056 Brignole et al. JACC Vol. 40, No. 11, 2002
Counter-Maneuvers Against Vasovagal Syncope December 4, 2002:2053–9

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.

Some physical counter-maneuvers have been proposed in
the management of orthostatic hypotension (13–16). These
mainly involve the muscles of the legs (leg-pumping and
tensing, leg-crossing) or legs and abdomen (abdominal
contraction, squatting). The increase in orthostatic BP is
presumed to be due both to mechanical compression of the
venous vascular bed in the legs and to a reflex increase in
systemic vascular resistances caused by the activation of
muscle mechanosensitive receptors. In a very recent uncon-
trolled study (17), leg crossing combined with tensing
muscles at the onset of prodromal symptoms, performed in
20/21 subjects, increased SBP from 65 ⫾ 13 mm Hg to 106
⫾ 16 mm Hg, postponed the faint by on average 2.5 min
and in five subjects prevented vasovagal syncope; during the
maneuver, symptoms disappeared in all patients. Cardiovas-
cular responses during HG have been studied in healthy and
in hypertensive patients (8 –10), but not in fainting patients.
Arm-tensing maneuvers have not been previously devel-
JACC Vol. 40, No. 11, 2002 Brignole et al. 2057
December 4, 2002:2053–9 Counter-Maneuvers Against Vasovagal Syncope

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.

oped. Muscle sympathetic nerve discharge and vascular
resistance increase during HG in healthy subjects (10). The
increase in arterial pressure can be achieved by increased
peripheral resistance alone in patients who lack the capacity
to increase HR or stroke volume because of surgical cardiac
denervation following cardiac transplantation (18) or phar-
macological blockade with propranolol (8). In one study
(19) there was no difference in the magnitude of cardiovas-
cular responses between HG performed with one and with
both hands; in another study (20) the magnitude of the
increase in muscle sympathetic nerve activity was greater
when the exercise was performed with two hands, but it was
less than the simple sum of the responses evoked with each
arm separately, suggesting that the sympathetic cardiovas-

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.
2058 Brignole et al.
Counter-Maneuvers Against Vasovagal Syncope
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.
cular adjustments elicited by separate limbs are not simply
additive, but rather exhibit an inhibitory interaction. We
observed similar responses between one-arm HG and two-
arm arm-tensing.
During tilt-induced vasovagal reaction, HG caused an
abrupt rise in systemic BP, which was already evident after
10 s. Consequently, symptoms of impending syncope dis-
appeared in many patients and remained unchanged in
others, and syncope was aborted. Conversely, in the control
arm, BP continued to fall slightly and approximately half of
the patients developed syncope after a mean of 66 s. The
benefits were maintained during the recovery phase, and
only 20% of patients ultimately developed syncope (vs. 58%
in the control arm). This finding means that isometric arm
contraction is able to abort syncope in most cases, even
when the patient remains in the standing position. The
practical consequence is that when symptoms of impending
syncope occur, the patient will have enough time to apply
the counter-pressure treatment before losing consciousness.
In some cases, the treatment will definitely abort the
vasovagal reaction, in others it will be able to delay syncope
for the duration of the maneuver, thus allowing enough time
to initiate other maneuvers to abort syncope (e.g., supine
posture). This approach seems to be very helpful in real life.
Indeed, during follow-up our patients were able to enact a
counter-pressure maneuver in 98% of cases and to relieve
symptoms in 99% of these. The treatment is therefore easy
to perform, reliable, safe and well accepted by the patients,
who expressed good satisfaction. Admittedly, most of these
episodes would have resolved spontaneously without leading
to syncope, even in the absence of the counter-pressure
treatment. Owing to the open design of the follow-up
study, we are unable to establish the exact benefit of the
treatment. A randomized trial should address this question.
In any case, counter-pressure maneuvers can be regarded as
JACC Vol. 40, No. 11, 2002
December 4, 2002:2053–9
a first-line treatment in association with the other conven-
tional measures usually recommended for vasovagal syn-
cope: namely, reassurance regarding the benign nature of
the condition, training in the recognition of premonitory
symptoms, avoidance of triggering events, the adoption of
maneuvers to abort the episode (e.g., supine posture), and
avoidance of volume depletion and prolonged upright pos-
ture. With regard to these latter treatment concepts, formal
randomized studies are also lacking, but physiological evi-
dence and clinical experience have been sufficient to warrant
their inclusion in the available guidelines (21).
Reprint requests and correspondence: Dr. Michele Brignole,
Department of Cardiology, Ospedali del Tigullio, Via don Bobbio,
16033 Lavagna, Italy. E-mail: mbrignole@ASL4.liguria.it.
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