Physical counterpressure manoeuvre trial.

1. Clinical diagnosis of classical neurally-mediated reflex syncope, based on the medical history ór non-classical diagnosis of neurally-mediated reflex syncope and a positive tilt-table test.

2. 3 syncope episodes in the last 2 years ór at least 1 syncopal spell in the last year and at least 3 episodes of presyncope in the last year;

3. Recognizable prodromal symptoms;

4. Age 16-70 years.

1. Suspected or certain heart disease and high likelihood of cardiac syncope:

a. Syncope preceded by palpitations or precordial pain;

b. Syncope during exercise;

c. Heart failure;

d. Ejection fraction < 40%;

e. Old or recent myocardial infarction;

f. Hypertrophic cardiomyopathy;

g. Dilated cardiomyopathy;

h. Significant valvular disease;

i. Sinus bradycardia < 50 bpm or sino-atrial blocks;

j. Mobitz I second degree atrioventricular block;

k. Mobitz II 2nd or 3rd degree atrioventricular block;

l. Complete bundle branch block;

m. Rapid paroxysmal supraventricular tachycardia or ventricular tachycardia;

n. Pre-excited QRS complexes;

o. Prolonged QT interval;

p. Right bundle branch block pattern with ST-elevation in leads V1-V3 (Brugada syndrome);

q. Negative T waves in right precordial leads, epsilon waves and ventricular late potentials suggestive of arrhythmogenic right ventricular dysplasia).

2. Orthostatic hypotension;

3. Episodes of loss of consciousness different from syncope (e.g. epilepsy, psychiatric, metabolic, drop-attack, TIA, intoxication, cataplexy);

4. Steal syndrome;

5. Psychologically or physically (due to any other illness) or cognitively unfit for participation in the study according to the opinion of the investigator;

6. Patient compliance doubtful;

7. Patient geographically or otherwise inaccessible for follow-up;

8. Patient unwilling or unable to give informed consent;

9. Pregnancy;

10. Life expectancy < 1 year.