Upright tilt table testing in the evaluation of syncope
- Brian Olshansky, MD
Brian Olshansky, MD
- Section Editor — Cardiac Arrhythmias
- Professor Emeritus of Medicine
- University of Iowa Hospitals and Clinics
The upright tilt table test is commonly performed for the evaluation of syncope, although the test has limited specificity, sensitivity, and reproducibility. It may be helpful particularly in young, otherwise healthy patients in whom the diagnosis of vasovagal (neurocardiogenic) syncope is suspected but not certain [1-3]. It is also useful in older persons in whom the cause of syncope remains unclear, but vasovagal syncope is suspected [3,4].
The utility of and protocol for tilt table testing will be reviewed here. The general evaluation of the patient with syncope and vasovagal syncope and other types of reflex (neurally-mediated) syncope is discussed separately. (See "Evaluation of syncope in adults" and "Reflex syncope".)
We agree with the 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope  and the 2009 European Society of Cardiology indications for upright tilt table testing in the following clinical settings :
Detailed autonomic testing, transthoracic echocardiogram, tilt-table testing, and exercise stress testing may be considered for selected patients being assessed for POTS:
●Recurrent episodes of syncope in the absence of organic heart disease, or in the presence of organic heart disease after cardiac causes of syncope have been excluded.
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- Brignole M, Menozzi C, Del Rosso A, et al. New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification. Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study. Europace 2000; 2:66.
- Kurbaan AS, Bowker TJ, Wijesekera N, et al. Age and hemodynamic responses to tilt testing in those with syncope of unknown origin. J Am Coll Cardiol 2003; 41:1004.
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- Sumiyoshi M, Nakata Y, Mineda Y, et al. Response to head-up tilt testing in patients with situational syncope. Am J Cardiol 1998; 82:1117.
- Sheldon R, Rose S, Koshman ML. Comparison of patients with syncope of unknown cause having negative or positive tilt-table tests. Am J Cardiol 1997; 80:581.
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- Brignole M, Sutton R, Menozzi C, et al. Lack of correlation between the responses to tilt testing and adenosine triphosphate test and the mechanism of spontaneous neurally mediated syncope. Eur Heart J 2006; 27:2232.
- Kabra R, Gopinathannair R, Sandesara C, et al. The dual role of implantable loop recorder in patients with potentially arrhythmic symptoms: a retrospective single-center study. Pacing Clin Electrophysiol 2009; 32:908.
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- TEST PROCEDURE
- Tilt protocol
- Isoproterenol infusion
- Use with other modalities
- - Carotid sinus massage
- - Clomipramine
- RESPONSE TO TILT TABLE TEST
- Test interpretation
- Test performance
- - False negative studies
- - Comparison to implantable loop recorder
- SUMMARY AND RECOMMENDATIONS