Which vagal maneuver should be avoided in patients with ischemic heart disease?

• A. Valsalva maneuver
• B. Head-down tilt with deep inspiration
• C. Facial immersion in ice water
• D. Carotid massage

Answer: (C)

In this context, the key idea is that vagal maneuvers can provoke a strong parasympathetic (vagal) response that slows the heart rate and AV node conduction. In ischemic heart disease, sudden, excessive vagal stimulation can lead to dangerous bradycardia and low blood pressure, which can worsen myocardial ischemia or cause arrhythmias. Facial immersion in ice water triggers a powerful diving reflex: cold that contacts the face activates vagal pathways and can produce abrupt, profound bradycardia or even transient asystole with hypotension. Because of this high risk, facial immersion in ice water should be avoided in patients with ischemic heart disease. The other maneuvers can be used with appropriate caution, but they do not carry the same potential for such a dramatic vagal surge.