Effect of Yoga on Clinical Outcomes and Quality of Life in Patients With Vasovagal Syncope (LIVE-Yoga)

The efficacy of non-pharmacological and non-pacing therapies in preventing vasovagal syncope: Tilt training, physical counter pressure maneuvers, and yoga - A systematic review and meta-analysis

BACKGROUND

Vasovagal syncope (VVS) is a prevalent condition characterized by a sudden drop in blood pressure and heart rate, leading to a brief loss of consciousness and postural control. Recurrent episodes of VVS significantly impact the quality of life and are a common reason for emergency department visits. Non-pharmacological interventions, such as tilt training, physical counter pressure maneuvers, and yoga, have been proposed as potential treatments for VVS. However, their efficacy in preventing VVS remains uncertain.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. PubMed, Web of Science, and Embase were searched up to March 2023 for randomized controlled trials comparing non-pharmacological interventions with control in preventing VVS recurrence. The primary outcome was the recurrence rate of VVS episodes.

RESULTS

A total of 1130 participants from 18 studies were included in the meta-analysis. The overall mean effect size for non-pharmacological interventions versus control was 0.245 (95 % CI: 0.128-0.471, p-value <0.001). Subgroup analysis showed that yoga had the largest effect size (odds ratio 0.068, 95 % CI: 0.018-0.250), while tilt training had the lowest effect size (odds ratio 0.402, 95 % CI: 0.171-0.946) compared to control. Physical counter pressure maneuvers demonstrated an odds ratio of 0.294 (95 % CI: 0.165-0.524) compared to control.

CONCLUSION

Non-pharmacological interventions show promise in preventing recurrent VVS episodes. Yoga, physical counter pressure maneuvers, and tilt training can be considered as viable treatment options. Further research, including randomized studies comparing pharmacological and non-pharmacological approaches, is needed to evaluate the safety and efficacy of these interventions for VVS treatment.

Effect of Integrated Yoga as an add-on therapy in adults with clinical depression - A randomized controlled trial

BACKGROUND

Depression is a leading cause of disability and the conventional management has several limitations. Recent studies demonstrated the benefits of yoga in psychological disorders.

AIMS

To evaluate the efficacy of the Integrated Yoga Module (IYM) to standard care with added yogic education on lifestyle modification (YELM) in patients with clinical depression.

METHODS

A PROBE trial was conducted at a single tertiary care hospital in India. Adults aged 18 to 64 with clinical depression were randomized to either an IYM or an active control group using a computer-generated mixed block randomization sequence. Both groups received YELM in addition to standard care and the intervention group practiced IYM, for 8 weeks. The primary outcome was the reduction in depression symptoms assessed using the Beck Depression Inventory (BDI-II), and secondary outcomes involved self-compassion, brief resilience, positive and negative experiences, and quality of life, evaluated at 8 weeks.

RESULTS

The mean ± SD age of participants was 32.2 ± 10.0 and 54.3% were females. The IYM group showed statistically significant improvements in BDI-II scores β = -6.7 (95% CI [-10.8, -2.5]; p = .001), resilience β = 0.4 (95% CI [0.02, 0.80]; p = .037), physical health domain of WHOQOL - BREF β = 10.1 (95% CI [0.7, 19.5]; p = .035) and negative emotions (SPANE-N) β = 2.8 (95% CI [0.1, 5.4]; p = .037). However, no significant differences were found in SCS-SF β = -0.3 (95% CI [-0.7, 0.0]; p = .053).

CONCLUSIONS

IYM as an adjunct is superior to conventional medical management in reducing symptoms and improving positive psychological resources in clinical depression.

Twenty-five years of research on syncope

Over the last 25 years, the Europace journal has greatly contributed to dissemination of research and knowledge in the field of syncope. More than 400 manuscripts have been published in the journal. They undoubtedly improved our understanding of syncope. This symptom is now clearly differentiated from other forms of transient loss of consciousness. The critical role of vasodepression and/or cardioinhibition as final mechanisms of reflex syncope is emphasized. Current diagnostic approach sharply separates between cardiac and autonomic pathways. Physiologic insights have been translated, through rigorously designed clinical trials, into non-pharmacological or pharmacological interventions and interventional therapies. The following manuscript is intended to give the reader the current state of the art of knowledge of syncope by highlighting landmark contributions of the Europace journal.

Current approach to the treatment of vasovagal syncope in adults

Vasovagal syncope (VVS) is the most common cause of transient loss of consciousness. Although not associated with mortality, it causes injuries, reduces quality of life, and is associated with anxiety and depression. The European and North American cardiac societies recently published syncope clinical practice guidelines. Most patients with VVS do well after specialist evaluation, reassurance and education. Adequate hydration, increased salt intake when not contraindicated, and careful withdrawal of diuretics and specific hypotension-inducing drugs are a reasonable initial strategy. Physical counterpressure maneuvers might be helpful but can be of limited efficacy in older patients and those with short or no prodromes. Orthostatic training lacks long term efficacy and is troubled by non-compliance. Yoga might be helpful, although the biomedical mechanism is unknown. Almost a third of VVS patients continue to faint despite these conservative measures. Metoprolol was not helpful in a pivotal randomized clinical trial. Fludrocortisone and midodrine significantly reduce syncope recurrences with tolerable side effects, when titrated to target doses. Pacing therapy with specialized sensors appears promising in carefully selected population who have not responded conservative measures. Cardioneuroablation may be helpful but has not been studied in a formal clinical trial.

Improved health-related quality of life after cardioneuroablation in patients with vasovagal syncope

BACKGROUND

As the most common cause of syncope, vasovagal syncope (VVS) is mediated by parasympathetic overactivity and/or sympathetic withdrawal. Although catheter ablation of ganglionated plexi or cardioneuroablation has been used to treat VVS, its role in quality of life (QoL) has not been formally evaluated. The aim of this study was to demonstrate if this novel treatment results in improvement QoL of patients with VVS.

METHODS

Twenty-seven consecutive patients (age: 34 ± 14 years, 51.8% male) with dominant cardioinhibitory type VVS were prospectively enrolled in the study. After confirmation of > 3 s asystole on head-up tilt testing (HUT), all patients underwent cardioneuroablation. ECGs were obtained prior to procedure and at 12-month follow-up visit. HUTs were repeated 1 month after cardioneuroablation procedures. QoL was assessed with the use of SF-36, EQ-5D, and EQ VAS questionnaires.

RESULTS

ECG, HUT, and QoL data were available in all patients. At 12-month follow-up, heart rate on rest ECG significantly increased (from 74 ± 15 to 84 ± 14 bpm, p = 0.003). Repeated HUTs were negative in 23 (85.1%) patients. All of 27 patients remained free of syncope. QoL assessed by SF-36 score significantly improved in postprocedural follow-up (92 ± 9 and 96 ± 11, p = 0.016). Similarly, significant improvements in mobility, self-care, and usual activity domains of EQ-5D were observed (mean scores of 3.0 ± 1.5 and 2.1 ± 1.3, p < 0.001; 1.3 ± 0.9 and 1.2 ± 0.6, p = 0.041; 1.7 ± 1.0 and 1.4 ± 0.8 respectively). EQ-VAS score also improved significantly (39 ± 24 to 77 ± 18, p < 0.001).

CONCLUSION

Our findings suggest that cardioneuroablation may be associated with intermediate term improvement in QoL in patients with VVS.

Mind and body interventions in cardiology : The importance of the brain-heart connection

Mind and body interventions aim to harness the "relaxation response", reduce stress, and improve quality of life, which is important in the search for more holistic treatment approaches in cardiovascular medicine. This article describes the pertinent pathophysiological correlates building the mechanistic backbone for these interventions. They can be found in the complex connections of brain and heart (central and autonomic nervous system, hypothalamic-pituitary-adrenal axis), which play an important role in the development of various cardiovascular disease conditions and hold potential as therapeutic targets. The evidence regarding the effect of mind and body interventions in cardiology with a focus on arrhythmia and psychocardiology is reviewed systematically. To date, mostly small pilot studies prone to substantial bias and without adequate power have dominated the field and longer-term outcome data are lacking. Ultimately, integration of mind and body interventions could empower patients by strengthening their individual responsibility and mental power in addition to the benefits of stress reduction and improvement of quality of life. Whether this will translate into relevant longer-term clinical outcomes remains uncertain. Therefore, this field offers multifaceted opportunities for further research and practical applications.