Upright tilt table testing in the evaluation of syncope
- Brian Olshansky, MD
Brian Olshansky, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- University of Iowa Medical Center
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.
- Grubb BP, Temesy-Armos P, Hahn H, Elliott L. Utility of upright tilt-table testing in the evaluation and management of syncope of unknown origin. Am J Med 1991; 90:6.
- Oribe E, Caro S, Perera R, et al. Syncope: the diagnostic value of head-up tilt testing. Pacing Clin Electrophysiol 1997; 20:874.
- 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.
- 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.
- 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.
- 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.
- Theodorakis GN, Markianos M, Zarvalis E, et al. Provocation of neurocardiogenic syncope by clomipramine administration during the head-up tilt test in vasovagal syndrome. J Am Coll Cardiol 2000; 36:174.
- Grubb BP, Samoil D, Kosinski D, et al. Cerebral syncope: loss of consciousness associated with cerebral vasoconstriction in the absence of systemic hypotension. Pacing Clin Electrophysiol 1998; 21:652.
- Carey BJ, Manktelow BN, Panerai RB, Potter JF. Cerebral autoregulatory responses to head-up tilt in normal subjects and patients with recurrent vasovagal syncope. Circulation 2001; 104:898.
- Kapoor WN, Brant N. Evaluation of syncope by upright tilt testing with isoproterenol. A nonspecific test. Ann Intern Med 1992; 116:358.
- 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.
- Englund A, Fredrikson M, Rosenqvist M. Head-up tilt test. A nonspecific method of evaluating patients with bifascicular block. Circulation 1997; 95:951.
- Leonelli FM, Wang K, Evans JM, et al. False positive head-up tilt: hemodynamic and neurohumoral profile. J Am Coll Cardiol 2000; 35:188.
- 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.
- Krahn AD, Klein GJ, Yee R, Skanes AC. Randomized assessment of syncope trial: conventional diagnostic testing versus a prolonged monitoring strategy. Circulation 2001; 104:46.
- 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