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Autonomic uprising: the tilt table test in autonomic medicine. Clin Auton Res 2019; 29:215-230. [DOI: 10.1007/s10286-019-00598-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/21/2019] [Indexed: 12/18/2022]
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2
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Bryarly M, Phillips LT, Fu Q, Vernino S, Levine BD. Postural Orthostatic Tachycardia Syndrome. J Am Coll Cardiol 2019; 73:1207-1228. [DOI: 10.1016/j.jacc.2018.11.059] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 11/01/2018] [Accepted: 11/05/2018] [Indexed: 12/26/2022]
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Abstract
INTRODUCTION We have observed electrocardiographic (ECG) changes primarily in women during tilt table testing. METHODS We reviewed 12 lead ECGs during tilt studies between 2012 and 2016 for changes in ST segments and T waves during tilt table testing. Patients with distinctly abnormal baseline ECGs were excluded. RESULTS Of the 180 tilt studies, 117 (65%) were in women. There were 32 patients with ECG changes during tilting. Of these, 28 (87.5%) were in women with an average age of 45years. None had a history of CAD or exertional chest pain. Echocardiograms were available in 21 of the 28 women with tilt induced ECG changes and all were normal. ECG changes during tilt table testing were found in 4/64 (6.25%) of men. The occurrence of ST-T wave changes during tilt testing was significantly higher among women compared to men, with a p value of 0.008. Of the 28 women with ECG changes during tilt, 11 had T wave inversions alone. ST segment depression alone was noted in 7 women. There were 10 women who had both ST segment depression and T wave inversions. Changes occurred immediately upon tilting in 6. In the remaining, they occurred at an average of 4.8±4min after tilting. The slight increase in heart rate in patients with ECG changes was similar to that in the patients without new ECG changes. The ECG changes were not related to the presence of syncope. CONCLUSIONS ECG changes during the testing was observed at a relatively high incidence primarily in women. The clinical significance of these repolarization changes during tilt testing is unknown. These ECG changes during tilt testing may correlate with the high incidence of false positive ECGs in women during exercise testing but do not necessarily indicate the presence of ischemic coronary disease. Additional research is needed to explain this phenomenon.
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Affiliation(s)
| | - Jagdesh Kandala
- Division of Cardiology, Sarver Heart Center, University of Arizona, Tucson, AZ, United States
| | - Frank I Marcus
- Division of Cardiology, Sarver Heart Center, University of Arizona, Tucson, AZ, United States.
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Tahvanainen AM, Tikkakoski AJ, Koskela JK, Nordhausen K, Viitala JM, Leskinen MH, Kähönen MAP, Kööbi T, Uitto MT, Viik J, Mustonen JT, Pörsti IH. The type of the functional cardiovascular response to upright posture is associated with arterial stiffness: a cross-sectional study in 470 volunteers. BMC Cardiovasc Disord 2016; 16:101. [PMID: 27216309 PMCID: PMC4877753 DOI: 10.1186/s12872-016-0281-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 05/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In a cross-sectional study we examined whether the haemodynamic response to upright posture could be divided into different functional phenotypes, and whether the observed phenotypes were associated with known determinants of cardiovascular risk. METHODS Volunteers (n = 470) without medication with cardiovascular effects were examined using radial pulse wave analysis, whole-body impedance cardiography, and heart rate variability analysis. Based on the passive head-up tilt induced changes in systemic vascular resistance and cardiac output, the principal determinants of blood pressure, a cluster analysis was performed. RESULTS The haemodynamic response could be clustered into 3 categories: upright increase in vascular resistance and decrease in cardiac output were greatest in the first (+45 % and -27 %, respectively), smallest in the second (+2 % and -2 %, respectively), and intermediate (+22 % and -13 %, respectively) in the third group. These groups were named as 'constrictor' (n = 109), 'sustainer' (n = 222), and 'intermediate' (n = 139) phenotypes, respectively. The sustainers were characterized by male predominance, higher body mass index, blood pressure, and also by higher pulse wave velocity, an index of large arterial stiffness, than the other groups (p < 0.01 for all). Heart rate variability analysis showed higher supine and upright low frequency/high frequency (LF/HF) ratio in the sustainers than constrictors, indicating increased sympathovagal balance. Upright LF/HF ratio was also higher in the sustainer than intermediate group. In multivariate analysis, independent explanatory factors for higher pulse wave velocity were the sustainer (p < 0.022) and intermediate phenotypes (p < 0.046), age (p < 0.001), body mass index (p < 0.001), and hypertension (p < 0.001). CONCLUSIONS The response to upright posture could be clustered to 3 functional phenotypes. The sustainer phenotype, with smallest upright decrease in cardiac output and highest sympathovagal balance, was independently associated with increased large arterial stiffness. These results indicate an association of the functional haemodynamic phenotype with an acknowledged marker of cardiovascular risk. TRIAL REGISTRATION ClinicalTrials.gov NCT01742702.
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Affiliation(s)
- Anna M Tahvanainen
- School of Medicine, University of Tampere, Tampere, Finland. .,School of Medicine / Internal Medicine, FIN-33014 University of Tampere, Tampere, Finland.
| | | | | | - Klaus Nordhausen
- Department of Mathematics and Statistics, University of Turku, Turku, Finland
| | - Jani M Viitala
- School of Medicine, University of Tampere, Tampere, Finland
| | | | - Mika A P Kähönen
- School of Medicine, University of Tampere, Tampere, Finland.,Department of Clinical Physiology, Tampere University Hospital, P.O. Box 2000, Tampere, 33521, Finland
| | - Tiit Kööbi
- Department of Clinical Physiology, Tampere University Hospital, P.O. Box 2000, Tampere, 33521, Finland
| | - Marko T Uitto
- School of Medicine, University of Tampere, Tampere, Finland.,Department of Electronics and Communication Engineering, Tampere University of Technology, BioMediTech, Tampere, Finland
| | - Jari Viik
- Department of Electronics and Communication Engineering, Tampere University of Technology, BioMediTech, Tampere, Finland
| | - Jukka T Mustonen
- School of Medicine, University of Tampere, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, P.O. Box 2000, Tampere, 33521, Finland
| | - Ilkka H Pörsti
- School of Medicine, University of Tampere, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, P.O. Box 2000, Tampere, 33521, Finland
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Saal D, Thijs R, van Dijk J. Tilt table testing in neurology and clinical neurophysiology. Clin Neurophysiol 2016; 127:1022-1030. [DOI: 10.1016/j.clinph.2015.07.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/20/2015] [Accepted: 07/23/2015] [Indexed: 11/29/2022]
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6
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Kim BG, Cho SW, Lee HY, Kim DH, Byun YS, Goh CW, Rhee KJ, Kim BO. Reduced systemic vascular resistance is the underlying hemodynamic mechanism in nitrate-stimulated vasovagal syncope during head-up tilt-table test. J Arrhythm 2015; 31:196-200. [PMID: 26336559 DOI: 10.1016/j.joa.2014.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 11/21/2014] [Accepted: 11/26/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Nitroglycerin (NTG) challenge during head-up tilt-table testing (HUTT) is often utilized to determine the etiology of unexplained vascular syncope. However, conflicting results concerning nitrate-induced hemodynamic changes during HUTT have been reported. The purpose of this study was to assess the determinants of presyncopal symptoms during NTG-stimulated HUTT. METHODS We evaluated 40 patients with suspected vasovagal syncope. Beat-to-beat changes in blood pressure, heart rate (HR), cardiac index (CI), and systemic vascular resistance (SVR) during HUTT were measured with thoracic impedance cardiography and a plethysmographic finger arterial pressure monitoring device. RESULTS None of the 40 patients complained of presyncopal symptoms during passive HUTT. However, after the administration of NTG 28 patients showed presyncopal symptoms (NTG+ group) and the remaining 12 patients did not (NTG- group). HR, CI, and the stroke index did not significantly differ between the two groups, whereas mean arterial pressure and SVR were significantly lower in the NTG+ group. CONCLUSIONS Presyncopal symptoms during NTG-stimulated HUTT are SVR mediated, not cardiac output mediated. This study challenges the conventional idea of a decrease in cardiac output mediated by NTG as the overriding cause of presyncopal symptoms during HUTT.
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Affiliation(s)
- Byung Gyu Kim
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik hospital, Inje University College of Medicine, Seoul 139-707, Republic of Korea
| | - Sung Woo Cho
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik hospital, Inje University College of Medicine, Seoul 139-707, Republic of Korea ; Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Hye Young Lee
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik hospital, Inje University College of Medicine, Seoul 139-707, Republic of Korea
| | - Deok Hee Kim
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik hospital, Inje University College of Medicine, Seoul 139-707, Republic of Korea
| | - Young Sup Byun
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik hospital, Inje University College of Medicine, Seoul 139-707, Republic of Korea
| | - Choong Won Goh
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik hospital, Inje University College of Medicine, Seoul 139-707, Republic of Korea
| | - Kun Joo Rhee
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik hospital, Inje University College of Medicine, Seoul 139-707, Republic of Korea
| | - Byung Ok Kim
- Division of Cardiology, Department of Internal Medicine, Sanggye Paik hospital, Inje University College of Medicine, Seoul 139-707, Republic of Korea
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Alasti M, Nikoo MH, Jadbabaei MH, Seyedian M, Payami B, Taghavianpour S, Omidvar B, Maghoumizadeh M, Azadi N. Randomized Prospective Comparison of Two Protocols for Head-up Tilt Testing in Patients with Normal Heart and Recurrent Unexplained Syncope. Indian Pacing Electrophysiol J 2013; 13:203-11. [PMID: 24482561 PMCID: PMC3876579 DOI: 10.1016/s0972-6292(16)30689-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND This randomized study was aimed to compare the diagnostic value of two head-up tilt testing protocols using sublingual nitroglycerin for provocation in patients with recurrent unexplained syncope and normal heart. METHODS The patients with normal findings in physical examination, electrocardiography and echocardiography were randomly submitted to one of upright tilt test protocols. The only difference between two protocols was that nitroglycerin was administered after a five minute resting phase in supine position during protocol B. We also considered eighty normal persons as the control group. RESULTS Out of 290 patients that underwent tilt testing, 132 patients were in group A versus 158 patients in group B. Both groups had an identical distribution of clinical characteristics. Tilt test was positive in 79 patients in group A (25 in passive phase, 54 in active phase) versus 96 patients in group B (43 in passive phase, 53 in active phase). There was no significant difference between results in two groups (P value= 0.127). Forty cases were tested with protocol A and forty underwent tilt testing with protocol B. Tilt test was positive in 4 cases with protocol A versus 3 cases in protocol B. The positive rates of tilt testing with protocol A was 60% while it was 61% in protocol B. The specificity of testing with protocol A was 90% and it was 92.5% in protocol B. CONCLUSIONS According to our data, adding a period of rest and returning to supine position before nitroglycerin administration had no additional diagnostic yield.
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Affiliation(s)
- Mohammad Alasti
- Department of Cardiology, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Hosein Nikoo
- Department of Cardiology, Kosar Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohommad Hosein Jadbabaei
- Department of Cardiology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Masoud Seyedian
- Department of Cardiology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Babak Payami
- Department of Cardiology, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Saman Taghavianpour
- Department of Cardiology, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Bita Omidvar
- Department of Internal Medicine, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Maghoumizadeh
- Department of Cardiology, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nasim Azadi
- Department of Cardiology, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Menon SD, Morillo CA. Nitroglycerine in HUTT - An explosion in Our Understanding of Unexplained Syncope? Indian Pacing Electrophysiol J 2013; 13:200-2. [PMID: 24482560 PMCID: PMC3876578 DOI: 10.1016/s0972-6292(16)30688-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Forleo C, Guida P, Iacoviello M, Resta M, Monitillo F, Sorrentino S, Favale S. Head-up tilt testing for diagnosing vasovagal syncope: a meta-analysis. Int J Cardiol 2012; 168:27-35. [PMID: 23041006 DOI: 10.1016/j.ijcard.2012.09.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 06/01/2012] [Accepted: 09/12/2012] [Indexed: 01/08/2023]
Abstract
BACKGROUND A systematic evaluation focused on sensitivity and specificity of head-up tilt testing (HUT) for diagnosing vasovagal syncope has not been previously performed. We conducted a meta-analysis of studies comparing HUT outcome between patients with syncope of unknown origin and control subjects without previous syncope. METHODS We searched Pubmed and Embase databases for all English-only articles concerning case-control studies estimating the diagnostic yield of HUT, and selected 55 articles, published before March 2012, including 4361 patients and 1791 controls. The influence of age, test duration, tilt angle, and nitroglycerine or isoproterenol stimulation on tilt testing outcome was analyzed. RESULTS Head-up tilt testing demonstrated to have a good overall ability to discriminate between symptomatic patients and asymptomatic controls with an area under the summary receiver-operating characteristics curve of 0.84 and an adjusted diagnostic odds ratio of 12.15 (p<0.001). A significant inverse relationship between sensitivity and specificity of tilt testing for each study was observed (p<0.001). At multivariate analysis, advancing age and a 60° tilt angle showed a significant effect in reducing sensitivity and increasing specificity of the test. Nitroglycerine significantly raised tilt testing sensitivity by maintaining a similar specificity in comparison to isoproterenol. CONCLUSIONS The results from this meta-analysis show the high overall performance of HUT for diagnosing vasovagal syncope. Our findings provide useful information for evaluating clinical and instrumental parameters together with pharmacological stressors influencing HUT accuracy. This could allow the drawing of tilt testing protocols tailored on the diagnostic needs of each patient with unexplained syncope.
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Affiliation(s)
- Cinzia Forleo
- Cardiology Unit, Emergency and Organ Transplantation Department, University of Bari, Bari, Italy.
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MACEDO PAULAG, ASIRVATHAM SAMUELJ, MAIA LEILA, NETO EUSTÁQUIOFERREIRA, ZANATTA ANDRÉ, NETO JOSÉSOBRAL, BARRETO JOSÉROBERTO, MAIA HENRIQUE, OLIVEIRA EDNAM, DA ROCHA JAIROM, MARGALHO CARLAS, SEIXAS TAMER, PERES AYRTON, SANTOS-NETO LEOPOLDO, LEITE LUIZR. Comparison of a Shortened Isosorbide Dinitrate-Potentiated Head-Up Tilt Testing with the Conventional Protocol: Tolerance and Diagnostic Accuracy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1005-11. [DOI: 10.1111/j.1540-8159.2012.03440.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Supine and upright haemodynamic effects of sublingual nitroglycerin and inhaled salbutamol. J Hypertens 2012; 30:297-306. [DOI: 10.1097/hjh.0b013e32834e4b26] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Macedo P, Leite LR, Asirvatham SJ, Hachul DT, Dos Santos-Neto LL, Shen WK. Head Up Tilt Testing: An Appraisal of Its Current Role in the Management of Patients with Syncope. J Atr Fibrillation 2011; 4:333. [PMID: 28496692 DOI: 10.4022/jafib.333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 12/19/2010] [Accepted: 01/14/2011] [Indexed: 01/14/2023]
Abstract
Head up tilt testing (HTT) is now commonly used to investigate otherwise unexplained syncope and presyncope. This test has been used for over 20 years primarily to diagnose neurally mediated syncope, but HTT's exact role in the diagnostic process remains uncertain. Recognized limitations include poor reproducibility, lack of prognostic role, and insufficient randomized studies to guide therapeutic choice. In this review, we describe the indications and methods recommended by present guidelines on utilizing HTT. In addition, present criticisms and limitations of this test, along with future perspectives, are outlined.
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Affiliation(s)
- Paula Macedo
- Division of Cardiovascular Diseases, Department of Medicine
| | | | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Medicine.,Department of Pediatrics and Adolescent Medicine - Mayo Clinic, Rochester, Minnesota
| | | | | | - Win-Kuang Shen
- Division of Cardiovascular Diseases, Department of Medicine
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Tahvanainen A, Koskela J, Leskinen M, Ilveskoski E, Nordhausen K, Kähönen M, Kööbi T, Mustonen J, Pörsti I. Reduced systemic vascular resistance in healthy volunteers with presyncopal symptoms during a nitrate-stimulated tilt-table test. Br J Clin Pharmacol 2011; 71:41-51. [PMID: 21143500 DOI: 10.1111/j.1365-2125.2010.03794.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Nitrates may facilitate syncope through various pathways, but the precise mechanism of nitrate-induced syncope is still under debate. The purpose of the present study was to compare the underlying haemodynamic mechanisms in subjects without and with presyncopal symptoms during a nitroglycerin-stimulated tilt-table test. WHAT THIS STUDY ADDS A major decrease in systemic vascular resistance was documented in subjects with presyncope during 0.25 mg nitroglycerin-stimulated tilt-table test, in the absence of changes in cardiac output. These findings indicated that even a small dose of nitroglycerin significantly decreased arterial resistance and cardiac afterload. AIMS The mechanism of nitrate-induced syncope remains controversial. We examined the haemodynamic changes in healthy volunteers during nitroglycerin-stimulated tilt-table test. METHODS Continuous radial pulse wave analysis, whole-body impedance cardiography and plethysmographic finger blood pressure were recorded in a supine position and during head-up tilt in 21 subjects with presyncopal symptoms (6 male/15 female, age 43 ± 3 years) after 0.25 mg sublingual nitroglycerin and 21 control subjects (6 male/15 female, age 43 ± 2 years). The drug was administered in the supine position and a passive head-up tilt followed 5 min later. Additionally, nitroglycerin was only administered during head-up tilt in 19 subjects and the haemodynamics were recorded. RESULTS Supine and upright haemodynamics were similar before nitroglycerin administration in the two groups. During the nitroglycerin-stimulated tilt test, aortic and radial mean blood pressure decreased significantly more in the presyncope group when compared with the controls (P= 0.0006 and P= 0.0004, respectively). The decreases in systemic vascular resistance (P= 0.0008) and heart rate (P= 0.002), and increase in aortic reflection time (P= 0.0002) were greater in the presyncope group, while the change in cardiac index was not different between the groups (P= 0.14). If nitroglycerin was administered during the upright tilt and not in supine position, the haemodynamic changes were quite corresponding. CONCLUSIONS Presyncopal symptoms during nitrate-stimulated tilt test were explained by decreased systemic vascular resistance and increased aortic reflection time, while cardiac output remained unchanged. These findings indicated reduced arterial resistance in nitroglycerin-induced presyncope.
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Affiliation(s)
- Anna Tahvanainen
- Department of Internal Medicine, Tampere School of Public Health, University of Tampere, Tampere, Finland.
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RODRIGUES THIAGODROCHA, STERNICK EDUARDOB, MOREIRA MARIADCONSOLAÇÃOVIEIRA. Epilepsy or Syncope? An Analysis of 55 Consecutive Patients with Loss of Consciousness, Convulsions, Falls, and No EEG Abnormalities. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:804-13. [DOI: 10.1111/j.1540-8159.2009.02685.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Clinical predictors of head-up tilt test outcome during the nitroglycerin phase. Clin Auton Res 2009; 20:167-73. [DOI: 10.1007/s10286-009-0020-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 06/10/2009] [Indexed: 11/26/2022]
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Flevari P, Leftheriotis D, Komborozos C, Fountoulaki K, Dagres N, Theodorakis G, Kremastinos D. Recurrent vasovagal syncope: comparison between clomipramine and nitroglycerin as drug challenges during head-up tilt testing. Eur Heart J 2009; 30:2249-53. [DOI: 10.1093/eurheartj/ehp255] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Swissa M, Epstein M, Paz O, Shimoni S, Caspi A. Head-up tilt table testing in syncope: safety and efficiency of isosorbide versus isoproterenol in pediatric population. Am Heart J 2008; 156:477-82. [PMID: 18760129 DOI: 10.1016/j.ahj.2008.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Accepted: 05/14/2008] [Indexed: 01/15/2023]
Abstract
BACKGROUND The aim of this study was to compare the diagnostic value and safety of sublingual isosorbid dinitrate (ISDN) with intravenous isoproterenol (ISOP) during head-up tilt table testing (HUTT) in pediatric patients with suspected neurocardiogenic syncope. METHODS One hundred thirty-six consecutive pediatric patients complaining of presyncope or syncope were submitted to HUTT for the first time. Those who did not develop syncope or presyncope during passive HUTT for 20 minutes underwent repeated HUTT with either 1.25 to 2.5 mg sublingual ISDN or intravenous ISOP (1-3 mug/min) for 20 minutes. There were 54 boys and 82 girls, aged 10 to 18 years with an average of 15.5 +/- 2.4 years and a median of 16 years. Among the patients with cardioinhibition or mixed responses, the severity of the bradyarrhythmia was scored 1 to 3 (restoration of effective rhythm within 10 seconds, 10-20 seconds, and >20 seconds while back to supine position, respectively). RESULTS During the passive period, 24 (17.6%) of 136 patients had a positive response to HUTT. Syncope was observed in another 44 patients during either ISDN or ISOP period (14/58 [24.1%] and 30/54 [55.5%] with ISDN vs ISOP, respectively, P < .05). The time to symptoms was shorter with both ISDN and ISOP compared with passive period (6.5 +/- 2.9, 6.3 +/- 5.9, and 10.3 +/- 4.4, minutes, respectively, P < .05). The severity score for cardioinhibition response was significantly higher with ISDN compared with the passive period and ISOP (2 +/- 0.8, 1.25 +/- 0.45, and 1.26 +/- 0.45, respectively, P < .01). CONCLUSIONS Sublingual ISDN is less sensitive and less safe compared to intravenous ISOP in assessing pediatric age patients with suspected neurocardiogenic syncope and with a negative result in tilt test without provocation. The simplicity of ISDN use should be weighed against the risk of longer symptoms with ISDN.
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Timoteo AT, Oliveira MM, Feliciano J, Antunes E, da Silva MN, Silva S, Santos S, Ferreira R. Head-up tilt testing with different nitroglycerin dosages: experience in elderly patients with unexplained syncope. Europace 2008; 10:1091-4. [PMID: 18684771 DOI: 10.1093/europace/eun196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Protocols using sublingual nitrates have been increasingly used to improve diagnostic accuracy of head-up tilt testing (HUT). Nevertheless, exaggerated responses to nitrates have been frequently described, particularly in elderly patients. The aim of this article is to evaluate, in an elderly population with unexplained syncope, whether the impact of sublingual nitroglycerin (NTG) used as a provocative agent is dose-dependent. METHODS AND RESULTS One hundred and twenty consecutive elderly patients submitted to HUT using NTG after an asymptomatic drug-free phase were studied. Patients were divided into three groups according to the NTG dosage: 500, 375 and 250 microg. The test was considered positive when there was reproduction of symptoms with bradycardia and/or arterial hypotension. A gradual decrease in the blood pressure after NTG was considered an exaggerated response to nitrates. There were no differences in the clinical characteristics of the different subgroups. A positive test was obtained in 50% of the patients in each group. The rate of exaggerated responses was identical in all groups and ranged between 15 and 17%. CONCLUSION In an elderly population with syncope of unknown origin submitted to HUT, the response to NTG is not dose-dependent, and no difference was found in the rate of exaggerated responses to nitrates with different NTG dosages.
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Affiliation(s)
- Ana Teresa Timoteo
- Cardiology Department, Santa Marta Hospital, R. Santa Marta, 1169-024 Lisboa, Portugal.
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Verheyden B, Gisolf J, Beckers F, Karemaker JM, Wesseling KH, Aubert AE, Wieling W. Impact of age on the vasovagal response provoked by sublingual nitroglycerine in routine tilt testing. Clin Sci (Lond) 2007; 113:329-37. [PMID: 17504242 DOI: 10.1042/cs20070042] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
NTG (nitroglycerine) is used in routine tilt testing to elicit a vasovagal response. In the present study we hypothesized that with increasing age NTG triggers a more gradual BP (blood pressure) decline due to a diminished baroreflex-buffering capacity. The purpose of the present study was to examine the effect of NTG on baroreflex control of BP in patients with distinct age-related vasovagal collapse patterns. The study groups consisted of 29 patients (16-71 years old, 17 females) with clinically suspected VVS (vasovagal syncope) and a positive tilt test. Mean FAP (finger arterial pressure) was monitored continuously (Finapres). Left ventricular SV (stroke volume), CO (cardiac output) and SVR (systemic vascular resistance) were computed from the pressure pulsations (Modelflow). BRS (baroreflex sensitivity) was estimated in the time domain. In the first 3 min after NTG administration, BP was well-maintained in all patients. This implied an adequate arterial resistance response to compensate for steeper reductions in SV and CO with increasing age. HR (heart rate) increased and the BRS decreased after NTG administration. The rate of mean FAP fall leading to presyncope was inversely related to age (r=0.51, P=0.005). Accordingly, patients with a mean FAP fall >1.44 mmHg/s (median) were generally younger compared with patients with a slower mean FAP-fall (30+/-10 years compared with 51+/-17 years; P=0.001). The main determinant of the rate of BP fall on approach of presyncope was the rate of fall in HR (r=0.75, P<0.001). It was concluded that, in older patients, sublingual NTG provokes a more gradual BP decline compared with younger patients. This gradual decline cannot be ascribed to failure of the baroreflex-buffering capacity with increasing age. Age-related differences in the laboratory presentation of a vasovagal episode depend on the magnitude of the underlying bradycardic response.
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Affiliation(s)
- Bart Verheyden
- Laboratory of Experimental Cardiology, University Hospital Gasthuisberg, K.U. Leuven, Leuven, Belgium.
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Vlahos AP, Tzoufi M, Katsouras CS, Barka T, Sionti I, Michalis LK, Siamopoulou A, Kolettis TM. Provocation of neurocardiogenic syncope during head-up tilt testing in children: comparison between isoproterenol and nitroglycerin. Pediatrics 2007; 119:e419-25. [PMID: 17224456 DOI: 10.1542/peds.2006-1862] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Although nitroglycerin- and isoproterenol-augmented tilt tests are of equal value in the diagnosis of neurocardiogenic syncope in adults, no data exist in children. We compared the sensitivity and specificity of the 2 tests in a pediatric population. PATIENTS AND METHODS We studied 85 patients (33 boys; mean age: 11.6 +/- 2.9 years). Of them, 56 had a diagnostic history of neurocardiogenic syncope, whereas 29 served as controls. After a negative passive phase, they were randomly assigned to either intravenous isoproterenol or sublingual nitroglycerin, and tilt was continued for 20 minutes. RESULTS Sensitivity was 0.78 for the isoproterenol test and 0.79 for the nitroglycerin test, but specificity was significantly higher for isoproterenol test compared with nitroglycerin test. In patients with a positive test, the duration of the recovery period was significantly longer after nitroglycerin (8.4 +/- 2.7 minutes) than after isoproterenol (5.1 +/- 1.6 minutes). CONCLUSIONS Nitroglycerin- and isoproterenol-augmented tilt tests are associated with equal sensitivity in the diagnosis of neurocardiogenic syncope in children and adolescents. However, nitroglycerin results in more false-positive tests and produces more prolonged vasovagal symptoms. Our data do not support the routine use of nitroglycerin in the evaluation of syncope in this age group.
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Affiliation(s)
- Antonios P Vlahos
- Child Health Department, Pediatric Cardiology Division, University of Ioannina, 45110 Ioannina, Greece.
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Mitro P, Hijová E. Myocardial Contractility and Cardiac Filling Measured by Impedance Cardiography in Patients with Nitroglycerine-Induced Vasovagal Syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:1-8. [PMID: 16441710 DOI: 10.1111/j.1540-8159.2006.00299.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Increased myocardial contractility and inadequate cardiac filling leading to activation of the Bezold-Jarisch reflex were proposed as possible triggering mechanisms of vasovagal syncope (VVS). In the present study noninvasive hemodynamic measurements were performed in order to examine the role of myocardial contractility and cardiac filling in pathogenesis of VVS. METHODS Hemodynamic parameters were measured during head-up tilt test (HUT) by impedance cardiography in 46 patients with unexplained syncope. Myocardial contractility was measured as index of contractility (IC), acceleration index (ACI), and ejection fraction (EF). Afterload was measured as systemic vascular resistance index (SVRI) and preload was expressed as end-diastolic index (EDI). Serial measurements were done 1 minute before HUT, during HUT at 1-minute intervals, and 1 minute after completion of HUT. RESULTS HUT was positive in 30 patients (10 men, 20 women, mean age 36 +/- 16 years) and negative in 16 patients (8 men, 8 women, mean age 31 +/- 14 years). No significant differences were observed between HUT(+) and HUT(-) groups in hemodynamic parameters at supine rest and during HUT until the development of syncope. SVRI was lower in HUT(+) than in HUT(-) group at syncope (122.7 + 66.3 vs 185.6 + 51.4 dyn sec cm(-5)/m2, P = 0.002) and after syncope (117.0 + 61.1 vs 198.0 + 95.7 dyn sec cm(-5)/m2, P = 0.007). ACI, IC, EF, and EDI did not differ between groups at syncope. After syncope EF was higher in HUT(+) group compared to HUT(-) group (59.2 + 6.1 vs 52.7 + 9.4%, P = 0.02). CONCLUSION The role of increased myocardial contractility and decreased cardiac filling is not confirmed in the present study.
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Affiliation(s)
- Peter Mitro
- Third Clinic of Internal Medicine, Kossice, Slovakia.
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Aerts AJJ, Dendale P, Block P, Dassen WRM. Reproducibility of nitrate-stimulated tilt testing in patients with suspected vasovagal syncope and a healthy control group. Am Heart J 2005; 150:251-6. [PMID: 16086926 DOI: 10.1016/j.ahj.2004.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2004] [Accepted: 08/01/2004] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Nitrate-stimulated tilt testing may be used to diagnose vasovagal syncope or to guide therapy. To date, the reproducibility of the test in patients with clinically suspected vasovagal syncope and healthy controls is undetermined. A high reproducibility is a prerequisite for correct interpretation of the test result. This study investigates the reproducibility of a nitrate-stimulated tilt test in patients with clinically suspected vasovagal syncope and a healthy control group. METHODS AND RESULTS We studied 43 patients (24 women, 19 men) with a typical history of vasovagal syncope and 18 healthy controls (3 women, 15 men). We used a combined tilt protocol with a 30-minute passive and 15-minute nitrate-stimulated phase. The second tilt test was performed 16 +/- 12 days after the first. In both patients and controls, overall positive tilt responses were reproduced in the second test in 100%. In contrast to this, the reproducibility of an overall negative test was 50% in patients but 93% in controls. Overall hemodynamic responses to tilt were reproducible in 80%. CONCLUSION Nitrate-stimulated tilt testing in both patients with suspected vasovagal syncope and controls has an excellent reproducibility of positive results but a moderate reproducibility of negative results. Importantly, these results are still valid at a repeat interval of 2 weeks and longer. These data suggest that in patients with suspected vasovagal syncope, a nitrate-stimulated tilt test may provide a suitable tool to evaluate the efficacy of a therapeutic approach.
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Affiliation(s)
- Arnaud J J Aerts
- Department of Cardiology, Atrium Medisch Centrum, Heerlen, The Netherlands.
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Aerts AJJ, Dendale P. Diagnostic Value of Nitrate Stimulated Tilt Testing Without Preceding Passive Tilt in Patients with Suspected Vasovagal Syncope and a Healthy Control Group. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:29-32. [PMID: 15660799 DOI: 10.1111/j.1540-8159.2005.09439.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The contribution of the passive tilt phase, in a combined nitrate stimulated tilt protocol may be low yielding. In order to develop a shortened, and thus easier to perform test, we investigated the optimal duration of a nitrate tilt protocol without a preceding passive phase. METHODS Thirty-eight consecutive patients (18F/20M; mean age 46 +/- 16) with clinically suspected vasovagal syncope and 31 control subjects (15F/16M; mean age 40 +/- 18) were tested. The subjects were tilted to 70 degrees for a maximum period of 30 minutes, and sublingual nitroglycerin 0.4 mg spray was administrated directly after attaining erect posture. Receiver operator characteristics (ROC) analysis was done to determine the optimal test duration. RESULTS In the patient group 31 (82%) and in controls 5 (16%) had a positive test. Sensitivity, specificity, and accuracy at test end were 82, 84, and 83%, respectively. ROC analysis revealed that a maximum accuracy of 83% was attained at 14 minutes, with a sensitivity and specificity of 79 and 87%, respectively. CONCLUSION Nitrate stimulated tilt testing, without a preceding passive tilt phase, and limited to a test duration of 15 minutes, provides an accurate, sensitive, and specific method to provoke vasovagal reactions in subjects with clinically suspected vasovagal syncope.
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Affiliation(s)
- Arnaud J J Aerts
- Department of Cardiology, Atrium Medical Centre, Heerlen, The Netherlands.
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Fisher JD. EDITORIAL COMMENT:. Tilt Testing Made Easy? Pacing Clin Electrophysiol 2005; 28:33. [PMID: 15660800 DOI: 10.1111/j.1540-8159.2005.09546.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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