By Joshua Moss, MD
Associate Professor of Clinical Medicine, Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
SYNOPSIS: Randomization to yoga in addition to standard care to treat vasovagal syncope led to better outcomes than standard care alone, with reductions in syncopal and presyncopal events and improvement in quality of life scores at one year.
SOURCE: Sharma G, Ramakumar V, Sharique M, et al. Effect of yoga on clinical outcomes and quality of life in patients with vasovagal syncope (LIVE-Yoga). JACC Clin Electrophysiol 2022;8:141-149.
Summary Points
- Of 270 patients screened, 55 with confirmed vasovagal syncope, including a positive tilt table test, at least two syncope or presyncope events in the prior six months, and no evidence for a secondary cause of syncope, were enrolled.
- The 30 patients randomized to the intervention arm were enrolled in a structured yoga program specially designed for the trial, including stretching and loosening exercises, breathing exercises, isotonic physical postures, controlled breathing, and meditation.
- The primary outcome measured was total number of episodes of syncope and presyncope. In the yoga intervention group, patients recorded a mean 0.7 events over 12 months. A total of 13 out of 30 reported no events. By comparison, patients receiving standard care alone reported significantly more syncope and presyncope, with a mean 2.5 events over 12 months.
Vasovagal syncope (VVS), also referred to as neurocardiogenic syncope or reflex fainting, is the most common form of syncope and can significantly affect quality of life. While not associated with higher mortality, VVS can result in injury. Multiple therapies have been tested, most without significant effect beyond placebo (which itself can be associated with improvement).
Sharma et al sought to test the effects of yoga on VVS in a controlled, randomized fashion. Of 270 patients screened, 55 with confirmed VVS, including a positive tilt table test, at least two syncope or presyncope events in the prior six months, and no evidence for a secondary cause of syncope, were enrolled. All patients were advised on standard therapies for VVS, including physical counterpressure maneuvers, increase in dietary salt and water intake, and trigger avoidance.
All patients participated in six-week, six-month, and 12-month follow-up visits, as well as twice-monthly phone calls. In addition, the 30 patients randomized to the intervention arm were enrolled in a structured yoga program specially designed for the trial, including stretching and loosening exercises, breathing exercises, isotonic physical postures, controlled breathing, and meditation. The yoga training included eight supervised sessions in the first two weeks, followed by self-guided home sessions five days per week and six additional supervised sessions in the first six months. No patient in either group was initiated on any pharmacologic agents or referred for a pacemaker.
The primary outcome measured was total number of episodes of syncope and presyncope. In the yoga intervention group, patients recorded a mean 0.7 events over 12 months. A total of 13 out of 30 reported no events. By comparison, patients receiving standard care alone reported significantly more syncope and presyncope, with a mean 2.5 events over 12 months. Only four of the 25 experienced no events. Secondary outcomes included quality of life assessments using the World Health Organization Brief Field Questionnaire and Syncope Functional Status HR-QoL Questionnaire, with significant improvement in the yoga intervention group that exceeded that of the control group.
Follow-up tilt table testing and heart rate variability measurements showed no significant difference between groups, but these were performed relatively early in the study (at six weeks). The authors concluded yoga, in addition to standard care to treat VVS, led to better outcomes than standard care alone.
COMMENTARY
This study adds evidence suggesting guided yoga training can treat VVS. There is biological plausibility to the intervention, with likely improved muscle tone from practicing isotonic physical postures, as well as relaxation techniques and mindfulness that could blunt the sympathetic drive of anxiety and stress (common triggers for clinical events). Reliable interventions for VVS beyond the conservative measures used in the control arm are limited. The ability to provide a combination of approaches not requiring medications or invasive procedures (e.g., midodrine, pacemakers, and catheter ablation targeting ganglionated plexi around the atria), especially in younger patients, is highly desirable.
The principal shortcoming of this study is the inability to truly isolate yoga itself as the primary driver of effect. Clinicians should beware the potentially significant placebo effect that might exist for nearly all VVS interventions. It is possible here that the more frequent contact with providers afforded the intervention group by virtue of frequent and regular supervised yoga visits was partially responsible for the better outcomes rather than the act of participating in yoga.
On one hand, it may be scientifically important to better isolate the effect of yoga training, perhaps with the inclusion of a sham yoga arm in an attempt to blind patients and providers to treatment assignment. On the other hand, for our patients with this non-life-threatening condition that often eventually improves with time — and for whom yoga may offer other benefits without any real risk — the exact answer may not be so critical. There is little downside in participating in a yoga program and excellent potential for benefit. I will be adding the recommendation to my routine care of patients with VVS.
