Upright tilt table testing in the evaluation of syncope
- David Benditt, MD
David Benditt, MD
- Professor of Medicine
- Director, Cardiac Arrhythmia Center
- University of Minnesota Medical School
The upright tilt table test is sometimes performed in the evaluation of a patient with suspected syncope. Tilt table testing may be helpful in patients in whom the diagnosis of vasovagal 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 [2,4].
The indications for tilt table testing, along with a description of the procedures and discussion of the results, will be reviewed here. The general evaluation of the patient with transient loss of consciousness (TLOC) and suspected syncope, as well as a detailed discussion of reflex syncope, are discussed separately. (See "Syncope in adults: Clinical manifestations and diagnostic evaluation" and "Reflex syncope in adults: Clinical presentation and diagnostic evaluation".)
DEFINITION AND CAUSES OF SYNCOPE
Syncope is a clinical syndrome in which transient loss of consciousness (TLOC) is caused by a period of inadequate cerebral nutrient flow, most often the result of an abrupt drop of systemic blood pressure. Typically, the inadequate cerebral nutrient flow is of relatively brief duration (8 to 10 seconds) and, in syncope, is by definition spontaneously self-limited.
Loss of postural tone is inevitable with loss of consciousness, and consequently syncope usually is associated with collapse, which may trigger injury due to a fall (such as may occur if the person is standing) or other type of accident (eg, if syncope occurs while driving). Recovery from true syncope is usually complete and rapid, with episodes rarely lasting more than a minute or two. Longer periods of real or apparent loss of consciousness suggest that the event is not syncope.
Syncope is but one form of TLOC. The possible causes of TLOC resulting in true syncope are generally grouped into four major categories:
- 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.
- Oribe E, Caro S, Perera R, et al. Syncope: the diagnostic value of head-up tilt testing. Pacing Clin Electrophysiol 1997; 20:874.
- Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol 2017.
- Grubb BP, Wolfe D, Samoil D, et al. Recurrent unexplained syncope in the elderly: the use of head-upright tilt table testing in evaluation and management. J Am Geriatr Soc 1992; 40:1123.
- 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.
- 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.
- Sheldon R, Rose S, Koshman ML. Isoproterenol tilt-table testing in patients with syncope and structural heart disease. Am J Cardiol 1996; 78:700.
- Leman RB, Clarke E, Gillette P. Significant complications can occur with ischemic heart disease and tilt table testing. Pacing Clin Electrophysiol 1999; 22:675.
- Almquist A, Goldenberg IF, Milstein S, et al. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med 1989; 320:346.
- Mallat Z, Vicaut E, Sangaré A, et al. Prediction of head-up tilt test result by analysis of early heart rate variations. Circulation 1997; 96:581.
- Shen WK, Jahangir A, Beinborn D, et al. Utility of a single-stage isoproterenol tilt table test in adults: a randomized comparison with passive head-up tilt. J Am Coll Cardiol 1999; 33:985.
- Aerts A, Dendale P, Strobel G, Block P. Sublingual nitrates during head-up tilt testing for the diagnosis of vasovagal syncope. Am Heart J 1997; 133:504.
- Zeng C, Zhu Z, Hu W, et al. Value of sublingual isosorbide dinitrate before isoproterenol tilt test for diagnosis of neurally mediated syncope. Am J Cardiol 1999; 83:1059.
- Aerts AJ, Dendale P, Daniels C, et al. Intravenous nitrates for pharmacological stimulation during head-up tilt testing in patients with suspected vasovagal syncope and healthy controls. Pacing Clin Electrophysiol 1999; 22:1593.
- Gisolf J, Westerhof BE, van Dijk N, et al. Sublingual nitroglycerin used in routine tilt testing provokes a cardiac output-mediated vasovagal response. J Am Coll Cardiol 2004; 44:588.
- Parry SW, Gray JC, Newton JL, et al. 'Front-loaded' head-up tilt table testing: validation of a rapid first line nitrate-provoked tilt protocol for the diagnosis of vasovagal syncope. Age Ageing 2008; 37:411.
- Raviele A, Giada F, Brignole M, et al. Comparison of diagnostic accuracy of sublingual nitroglycerin test and low-dose isoproterenol test in patients with unexplained syncope. Am J Cardiol 2000; 85:1194.
- Delépine S, Prunier F, Lefthériotis G, et al. Comparison between isoproterenol and nitroglycerin sensitized head-upright tilt in patients with unexplained syncope and negative or positive passive head-up tilt response. Am J Cardiol 2002; 90:488.
- Kapoor WN, Brant N. Evaluation of syncope by upright tilt testing with isoproterenol. A nonspecific test. Ann Intern Med 1992; 116:358.
- Leonelli FM, Wang K, Evans JM, et al. False positive head-up tilt: hemodynamic and neurohumoral profile. J Am Coll Cardiol 2000; 35:188.
- Fitzpatrick AP, Lee RJ, Epstein LM, et al. Effect of patient characteristics on the yield of prolonged baseline head-up tilt testing and the additional yield of drug provocation. Heart 1996; 76:406.
- 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.
- DEFINITION AND CAUSES OF SYNCOPE
- TILT TABLE TESTING PROCEDURE
- Patient preparation and necessary equipment
- Tilt protocol
- - Starting the test
- - Passive phase
- - Drug provocation phase
- Comparison of isoproterenol and nitroglycerin
- TILT TABLE TEST RESULTS
- Test interpretation
- Test performance
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS