Hemodynamic effects of leg crossing and skeletal muscle tensing during free standing in patients with vasovagal syncope

Departments of 1 Internal Medicine, 2 Physiology, and 3 Cardiology, Academic Medical Center, Amsterdam, The Netherlands; and 4 Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin Submitted 14 July 2004 ; accepted in final form 3 October 2004 Physical maneuvers can be applied to abort or delay an impending vasovagal faint. These countermaneuvers would be more beneficial if applied as a preventive measure. We hypothesized that, in patients with recurrent vasovagal syncope, leg crossing produces a rise in cardiac output (CO) and thereby in blood pressure (BP) with an additional rise in BP by muscle tensing. We analyzed the age and gender effect on the BP response. To confirm that, during the maneuvers, Modelflow CO changes in proportion to actual CO, 10 healthy subjects performed the study protocol with CO evaluated simultaneously by Modelflow and by inert gas rebreathing. Changes in Modelflow CO were similar in direction and magnitude to inert gas rebreathing-determined CO changes. Eighty-eight patients diagnosed with vasovagal syncope applied leg crossing after a 5-min free-standing period. Fifty-four of these patients also applied tensing of leg and abdominal muscles. Leg crossing produced a significant rise in CO (+9.5%; P < 0.01) and thereby in mean arterial pressure (+3.3%; P < 0.01). Muscle tensing produced an additional increase in CO (+8.3%; P < 0.01) and mean arterial pressure (+7.8%; P < 0.01). The rise in BP during leg crossing was larger in the elderly. blood pressure; cardiac output; physical counterpressure maneuvers; inert gas rebreathing; Modelflow Address for reprint requests and other correspondence: N. van Dijk, Academic Medical Center, Dept. of Internal Medicine, PO Box 22660, 1100 DD Amsterdam, The Netherlands (E-mail: n.vandijk{at}amc.uva.nl )