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van Zanten S, Sutton R, Hamrefors V, Fedorowski A, de Lange FJ. Tilt table testing, methodology and practical insights for the clinic. Clin Physiol Funct Imaging 2024; 44:119-130. [PMID: 37839043 DOI: 10.1111/cpf.12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value.
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Affiliation(s)
- Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Brignole M, Kessisoglu F, Croci F, Solano A, Donateo P, Maggi R, Solari D, Bertolone C, Fontana D, Oddone D, Rivasi G, Rafanelli M, Casini N, Ungar A. Complementary effectiveness of carotid sinus massage and tilt testing for the diagnosis of reflex syncope in patients older than 40 years: a cohort study. Europace 2021; 22:1737-1741. [PMID: 33078193 DOI: 10.1093/europace/euaa204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/23/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Indications, methodology, and diagnostic criteria for carotid sinus massage (CSM) and tilt testing (TT) have been standardized by the 2018 Guidelines on Syncope of the European Society of Cardiology. Aim of this study was to assess their effectiveness in a large cohort which reflects the performance under 'real-world' conditions. METHODS AND RESULTS We analysed all patients who had undergone CSM and TT in the years 2003-2019 for suspected reflex syncope. Carotid sinus massage was performed according to the 'Method of Symptoms'. Tilt testing was performed according to the 'Italian protocol' which consists of a passive phase followed by a sublingual nitroglycerine phase. For both tests, positive test was defined as reproduction of spontaneous symptoms in the presence of bradycardia and/or hypotension. Among 3293 patients (mean age 73 ± 12 years, 48% males), 2019 (61%) had at least one test positive. A bradycardic phenotype was found in 420 patients (13%); of these, 60% were identified by CSM, 37% by TT, and 3% had both test positive. A hypotensive phenotype was found in 1733 patients (53%); of these, 98% were identified by TT and 2% had both TT and CSM positive. CONCLUSION The overall diagnostic yield of the tests in patients >40-year-old with suspected reflex syncope was 61%. Both CSM and TT are useful for identifying those patients with a bradycardic phenotype, whereas CSM has a limited value for identifying the hypotensive phenotype. Since the overlap of responses between tests is minimal, both CSM and TT should be performed in every patient over 40 years receiving investigation for unexplained but possible reflex syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Ospedale San Luca, Milano, Italy
| | | | - Francesco Croci
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Alberto Solano
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Paolo Donateo
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Roberto Maggi
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Diana Solari
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Cristina Bertolone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Daniele Fontana
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Daniele Oddone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Giulia Rivasi
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Martina Rafanelli
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Niccolò Casini
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Andrea Ungar
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
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