Upright tilt table testing in the evaluation of syncope
- Brian Olshansky, MD
Brian Olshansky, MD
- Section Editor — Cardiac Arrhythmias
- Adjunct Professor of Medicine
- Des Moines University
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.
- Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631.
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- Sheldon RS, Grubb BP 2nd, Olshansky B, et al. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm 2015; 12:e41.
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- Moya A, Brignole M, Menozzi C, et al. Mechanism of syncope in patients with isolated syncope and in patients with tilt-positive syncope. Circulation 2001; 104:1261.
- 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.
- Kochiadakis GE, Papadimitriou EA, Marketou ME, et al. Autonomic nervous system changes in vasovagal syncope: is there any difference between young and older patients? Pacing Clin Electrophysiol 2004; 27:1371.
- 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.
- Lacroix D, Kouakam C, Klug D, et al. Asystolic cardiac arrest during head-up tilt test: incidence and therapeutic implications. Pacing Clin Electrophysiol 1997; 20:2746.
- 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