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Thijs RD, Brignole M, Falup-Pecurariu C, Fanciulli A, Freeman R, Guaraldi P, Jordan J, Habek M, Hilz M, Traon APL, Stankovic I, Struhal W, Sutton R, Wenning G, Van Dijk JG. Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN). Clin Auton Res 2021; 31:369-384. [PMID: 33740206 PMCID: PMC8184725 DOI: 10.1007/s10286-020-00738-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/12/2020] [Indexed: 12/17/2022]
Abstract
An expert committee was formed to reach consensus on the use of tilt table testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous events. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to the performance of (1) additional provocation tests, such as the active standing test, carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; and (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.
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Affiliation(s)
- Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.
| | - Michele Brignole
- Faint and Fall Programme, Department of Cardiology, Ospedale San Luca, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Cardiology and Arrhythmologic Centre, Ospedali del Tigullio, 16033, Lavagna, Italy
| | - Cristian Falup-Pecurariu
- Department of Neurology, County Emergency Clinic Hospital, Transilvania University, Brasov, Romania
| | | | - Roy Freeman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Pietro Guaraldi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Jens Jordan
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne, Germany
- Chair of Aerospace Medicine, University of Cologne, Cologne, Germany
- University Hypertension Center, Cologne, Germany
| | - Mario Habek
- Referral Center for Autonomic Nervous System, Department of Neurology, School of Medicine, University Hospital Center Zagreb, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
| | - Max Hilz
- Department of Neurology, University Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne Pavy-Le Traon
- Neurology Department, French Reference Center for MSA, University Hospital of Toulouse and INSERM U 1048, Toulouse, France
| | - Iva Stankovic
- Clinical Center of Serbia, Neurology Clinic, University of Belgrade, Belgrade, Serbia
| | - Walter Struhal
- Department of Neurology, University Clinic Tulln, Karl Landsteiner University of Health Sciences, Tulln, Austria
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Hammersmith Hospital, Ducane Road, London, W12 0NN, UK
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Gert Van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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Thijs RD, Brignole M, Falup-Pecurariu C, Fanciulli A, Freeman R, Guaraldi P, Jordan J, Habek M, Hilz M, Pavy-LeTraon A, Stankovic I, Struhal W, Sutton R, Wenning G, van Dijk JG. Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN). Auton Neurosci 2021; 233:102792. [PMID: 33752997 DOI: 10.1016/j.autneu.2021.102792] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
An expert committee was formed to reach consensus on the use of Tilt Table Testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous ones. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to perform (1) additional provocation tests, such as the active standing test carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.
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Affiliation(s)
- Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands.
| | - Michele Brignole
- Faint & Fall Programme, Department of Cardiology, Ospedale San Luca, IRCCS Istituto Auxologico Italiano, Milan, Italy; Department of Cardiology and Arrhythmologic Centre, Ospedali del Tigullio, 16033 Lavagna, Italy
| | - Cristian Falup-Pecurariu
- Department of Neurology, County Emergency Clinic Hospital, Transilvania University, Brasov, Romania
| | | | - Roy Freeman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Pietro Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Jens Jordan
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne, Germany; Chair of Aerospace Medicine, University of Cologne, Cologne, Germany; University Hypertension Center, Cologne, Germany
| | - Mario Habek
- Referral Center for Autonomic Nervous System, Department of Neurology, University Hospital Center Zagreb, University of Zagreb, School of Medicine, Kispaticeva 12, HR-10000 Zagreb, Croatia
| | - Max Hilz
- Department of Neurology, University Erlangen-Nuremberg, Germany; Dept. of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne Pavy-LeTraon
- French reference center for MSA, Neurology department, University Hospital of Toulouse and INSERM U 1048, Toulouse, France
| | - Iva Stankovic
- Neurology Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Walter Struhal
- Department of Neurology, University Clinic Tulln, Karl Landsteiner University of Health Sciences, Tulln, Austria
| | - Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital, Ducane Road, London W12 0NN, UK
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
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Cardioinhibitory syncope: from pathophysiology to treatment—should we think on cardioneuroablation? J Interv Card Electrophysiol 2020; 59:441-461. [DOI: 10.1007/s10840-020-00758-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 04/23/2020] [Indexed: 02/07/2023]
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Glockler A, Cismaru G, Istratoaie S, Gusetu G, Zdrenghea D, Pop D, Rosu R. What is the optimal duration of the TILT after administration of 0.4 mg nitroglycerin spray? Medicine (Baltimore) 2020; 99:e19510. [PMID: 32176097 PMCID: PMC7440280 DOI: 10.1097/md.0000000000019510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Performing a head-up tilt test can be of great value for the diagnosis of vasovagal syncope. The European Society of Cardiology recommends a drug challenge phase duration of 15 to 20 minutes, with either Isoprenaline or Nitroglycerin administration.We sought to investigate the outcome of a ten-minute active phase with Nitroglycerin in patients suspected of vasovagal syncope and determine the percentage of loss in the positivity rate, using this short duration approach.We consecutively enrolled patients presenting with syncope undergoing the head-up tilt test (HUTT), with a clinical suspicion of vasovagal syncope between the years 2009 to 2019. The HUTT consisted of 2 successive phases: passive and active. During the passive phase, the patients were tilted at 70° for 20 minutes. If negative, the test was continued after administration of 0.4 mg sublingual Nitroglycerin. Applying the (VASIS) Vasovagal Syncope International Study classification of the vasovagal syncope international study and comparing for age and gender, positive responses were categorized into 3 types.A number of 306 patients (age = 43.5 +/-20.3; male = 140 [45.7%]) with suspected vasovagal syncope, undergoing HUTT, were enrolled in the years of 2009 to 2019. Of those, 245 (80.2%) presented a positive test, with 200 patients (82.0%) during the being positive during the active phase of the test. The results were as follows: 116 subjects (47.2%) presented with a mixed response (VASIS I), 52 (21.3%) showed a cardio inhibitory response (VASIS II), and 77 (31.5%) displayed a vasodepressor response (VASIS III). We found no relationship between the type of syncope with neither gender, nor age of the patient. Three minutes represented the median time to positivity, after Nitroglycerine administration. The time distribution showed a peak incidence appearing between minutes 3 and 5, ranging from 1 to 20 minutes. Only 3 patients tested positive after minute 10.Shortening the active phase to 10 minutes would result in a positivity rate loss of 1.5%.
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Rivasi G, Rafanelli M, Ungar A. Usefulness of Tilt Testing and Carotid Sinus Massage for Evaluating Reflex Syncope. Am J Cardiol 2018; 122:517-520. [PMID: 29954601 DOI: 10.1016/j.amjcard.2018.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/14/2018] [Accepted: 04/17/2018] [Indexed: 11/18/2022]
Abstract
Thirty years ago Tilt Testing (TT) was described as a tool in the diagnostic work-up of vasovagal syncope; after its initial success, some flaws have become evident. The concept of hypotensive susceptibility has provided the test a new relevance, shifting from diagnosis only, to therapeutic management. Carotid Sinus Massage (CSM) was introduced at the beginning of the XX century; the technique has evolved over years, whereas the concept of carotid sinus syndrome (CSS) has remained unchanged and uncontested for more than half a century. Nowadays, CSS is a matter of debate, with new classifications and criteria coming on the scene. Recently, a common central etiological mechanism has been hypothesized for reflex syncope, manifesting as CSS, vasovagal syncope or both. In this context, TT and CSM acquire an important role in clinical practice, being essential for a complete diagnosis and treatment. Recalling their historical background, the present paper illustrates an actual interpretation of TT and CSM.
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Affiliation(s)
- Giulia Rivasi
- Syncope Unit, Geriatric Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Martina Rafanelli
- Syncope Unit, Geriatric Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Syncope Unit, Geriatric Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
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Tilt testing and what you should know about it - Experience with 835 consecutive patients with syncope of unknown origin. Int J Cardiol 2018; 258:90-96. [DOI: 10.1016/j.ijcard.2018.01.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 01/22/2018] [Indexed: 11/22/2022]
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Ungar A, Rivasi G, Rafanelli M, Toffanello G, Mussi C, Ceccofiglio A, McDonagh R, Drumm B, Marchionni N, Alboni P, Kenny RA. Safety and tolerability of Tilt Testing and Carotid Sinus Massage in the octogenarians. Age Ageing 2016; 45:242-8. [PMID: 26833302 DOI: 10.1093/ageing/afw004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/12/2015] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE to evaluate the safety and tolerability of Tilt Testing (TT) and Carotid Sinus Massage (CSM) in octogenarians with unexplained syncope. METHODS patients consecutively referred for transient loss of consciousness to the 'Syncope Units' of three hospitals were enrolled. TT and CSM were performed according to the European Society of Cardiology guidelines on syncope. Complications were evaluated in each group. An early interruption of TT was defined as 'intolerance' and considered as a non-diagnostic response. RESULTS one thousand four hundred and one patients were enrolled (mean age 72 ± 16 years, male 40.8%). Six hundred and ninety-four patients (49.5%) were 80 years old or older (mean age 83 ± 3 years) and 707 (50.5%) were younger (mean age 60 ± 17 years). Complications after TT occurred in 4.5% of older patients and in 2.1% of the younger ones (P = 0.01). All complications were 'minor/moderate', as prolonged hypotension, observed in ∼3% of patients ≥80 years. Major complications such as sustained ventricular tachycardia, ventricular fibrillation, asystole requiring cardiac massage, transient ischaemic attack, stroke and death were not observed in any patient. The presence of orthostatic hypotension and the mean number of syncopal episodes were predictors of TT complications. Intolerance was reported in 2.4% of older patients and 1% of the younger ones (P = 0.08), mainly due to orthostatic intolerance. No complications occurred after CSM. CONCLUSIONS TT and CSM appear to be safe and well tolerated in octogenarians, who should not be excluded by age from the diagnostic work-up of syncope.
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Affiliation(s)
- Andrea Ungar
- Geriatric Cardiology and Medicine, University of Florence and Careggi Hospital, Florence, Italy
| | - Giulia Rivasi
- Geriatric Cardiology and Medicine, University of Florence and Careggi Hospital, Florence, Italy
| | - Martina Rafanelli
- Geriatric Cardiology and Medicine, University of Florence and Careggi Hospital, Florence, Italy
| | - Giulia Toffanello
- Geriatric Cardiology and Medicine, University of Florence and Careggi Hospital, Florence, Italy
| | - Chiara Mussi
- Geriatric and Gerontology Institute, University of Modena and Reggio Emilia, Modena, Italy
| | - Alice Ceccofiglio
- Geriatric Cardiology and Medicine, University of Florence and Careggi Hospital, Florence, Italy
| | - Ruth McDonagh
- Department of Neurology, Trinity College, Dublin, Ireland
| | - Breffni Drumm
- School of Medicine and Institute of Neuroscience, Trinity College, St James's Hospital, Dublin, Ireland
| | - Niccolò Marchionni
- Geriatric Cardiology and Medicine, University of Florence and Careggi Hospital, Florence, Italy
| | - Paolo Alboni
- Section of Cardiology and Syncope Unit, Ospedale Privato Quisisana, Ferrara, Italy
| | - Rose Anne Kenny
- School of Medicine and Institute of Neuroscience, Trinity College, St James's Hospital, Dublin, Ireland
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Watanabe N, Kawasaki S, Oonishi Y, Onuma Y, Munetsugu Y, Itou T, Onuki T, Miyoshi F, Minoura Y, Adachi T, Kawamura M, Asano T, Tanno K, Kobayashi Y. Characteristics of head-up tilt testing with additional adenosine compared with head-up tilt testing with isoproterenol and isosorbide dinitrate. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Mereu R, De Barbieri G, Perrone T, Mugellini A, Di Toro A, Bernardi L. Heart rate/blood pressure ratio as predictor of neuromediated syncope. Int J Cardiol 2013; 167:1170-5. [DOI: 10.1016/j.ijcard.2012.03.115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 02/03/2012] [Accepted: 03/10/2012] [Indexed: 12/25/2022]
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Abstract
Syncope is a major healthcare problem with significant morbidity, mortality and healthcare cost. It is a common symptom with a complex pathophysiology and, therefore, several aetiologies. Tilt-table testing (TTT) is an important, yet perhaps not widely-used, test that forms part of the management of syncope. We sought to assess the utilisation of this test in our institution for the investigation of patients with syncope, to study the referral patterns and the outcomes and usefulness of the TTT in a real-life setting. We undertook a retrospective study of all the TTT that were performed in our institution between January 2009 and October 2009. Of the 69 patients in which TTT was performed, 14 (20%) presented with presyncope, 24 (35%) with a single episode of syncope and 24 (44%) with multiple episodes. The average age was 57.2 years and 64% were female. Of the total patients, 35 (51%) had an abnormal TTT. Of the patients with normal TTT, four had internal loop recorders and six were referred to other medical specialities. The remaining patients (49%) had no formal diagnosis and were referred back to their general practitioner. TTT remains a common test modality and has great value when undertaken in the correct clinical context. This underlines the importance of a detailed clinical history. The European Society of Cardiology guidelines ensure a methodical and rational approach to syncopal patients and aide in choosing the right patient for the right test.
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Affiliation(s)
| | - Pervez Khan
- Goodhope Hospital, Sutton Coldfield, West Midlands, UK
| | - John Panting
- Goodhope Hospital, Sutton Coldfield, West Midlands, UK
| | - Sunil Nadar
- Goodhope Hospital, Sutton Coldfield, West Midlands, UK
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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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13
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Zyśko D, Gajek J, Terpiłowski L, Agrawal AK, Wróblewski P, Rudnicki J. Effects of the menstrual cycle phases on the tilt testing results in vasovagal patients. Arch Gynecol Obstet 2012; 286:429-35. [PMID: 22491807 DOI: 10.1007/s00404-012-2308-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Accepted: 03/20/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Dorota Zyśko
- Teaching Department for Emergency Medical Services, Wroclaw Medical University, Bartla 5, 51-618 Wrocław, Poland.
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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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15
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Parry SW, Gray JC, Newton JL, Reeve P, O'Shea D, Kenny RA. '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; 37:411-5. [PMID: 18586835 DOI: 10.1093/ageing/afn098] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Head-up tilt testing is the investigation of choice in the diagnosis of vasovagal syncope. The test is time consuming and labour intensive, with conventional tilt testing taking up to 45 min. We compared a shortened 'front-loaded' 20-min glyceryl trinitrate-provoked head-up tilt (FLGTN-HUT) with the standard 40-min passive tilt (HUT) as first line investigations in patients with unexplained syncope and asymptomatic controls. In the study, 149 consecutive patients with unexplained syncope and 83 asymptomatic controls were enrolled. Subjects were randomly assigned to FLGTN-HUT (800 mcg, metred spray) or HUT, then the opposite tilt-test 1 week later. Seventeen (11.4%) patients had diagnostic haemodynamic changes and symptom reproduction during HUT and 54 (36.2%) during FLGTN-HUT. A total of 24.8% more patients had a positive test with FLGTN-HUT than with passive HUT (95% CI: 16.3%, 33.4%). Nine (10.8%) controls had significant haemodynamic changes during HUT and 23 (27.7%) during GTN provocation. Seven controls had haemodynamic changes on both HUT and FLGTN-HUT testing. The controls group had 16.8% more significant haemodynamic changes with FLGTN-HUT than with HUT (95% CI: 0.06, 27.4). The front-loaded GTN protocol provided a higher diagnostic rate than passive tilt testing, and provides a rapid alternative to conventional methods, though false positivity rates are higher.
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Affiliation(s)
- Steve W Parry
- Falls and Syncope Service and Institute for Ageing and Health, Newcastle University, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.
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17
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A multi-center study of hemodynamic characteristics exhibited by children with unexplained syncope. Chin Med J (Engl) 2006. [DOI: 10.1097/00029330-200612020-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Salamé E, Neemtallah R, Azar R, Antonios S, Jazra C, Kassab R. [Sensitization of tilt-table testing for syncope of unknown etiology: which drug to use?]. Ann Cardiol Angeiol (Paris) 2006; 55:135-9. [PMID: 16792028 DOI: 10.1016/j.ancard.2005.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
OBJECTIVE The sensitivity of tilt-table testing in the diagnosis of vasovagal syncope is between 30% and 50% only. The most common method currently used to improve the sensitivity of the test is the administration of isoproterenol i.v. However, this method is difficult to perform and time consuming. The objective of our study was to compare sublingual trinitrin administration to i.v. isoproterenol during tilt-table testing. METHODS We analyzed the results of 257 consecutive patients referred for tilt testing. Patients who had a negative test received either a ten minutes infusion of i.v. isoproterenol at the dose of 4 mcg/kg/min, or 0.4 mg of trinitrin given sublingually. RESULTS Two hundred (and) fifty-seven patients underwent tilt-table testing. In the first group (isoproterenol group), 42 patients (39%) had a spontaneous positive tilt test, compared to 45 patients (31%) in the trinitrin group (P = NS). After sensitization, 24 additional patients (22%) had a positive test in the isoproterenol group vs 55 patients (37%) in the trinitrin group (P = NS). The total number of positive tests was 66 (61%) in the isoproterenol group compared to 100 (68%) in the trinitrin group (P = NS). CONCLUSION Sublingual trinitrin is at least as good as IV isoproterenol during tilt-table testing. Because trinitrin is simpler to use and because its administration is much faster than isoproterenol, it should be recommended as the drug of choice to improve the sensitivity of tilt-table testing.
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Affiliation(s)
- E Salamé
- Service de cardiologie, hôpital Hôtel-Dieu-de-France, rue Alfred-Naccache, Beyrouth, Liban.
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Seidl K, Schuchert A, Tebbenjohanns J, Hartung W. [Commentary on the guidelines the diagnosis and the therapy of syncope--the European Society of Cardiology 2001 and the update 2004]. ACTA ACUST UNITED AC 2005; 94:592-612. [PMID: 16142520 DOI: 10.1007/s00392-005-0230-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- K Seidl
- Herzzentrum Ludwigshafen, Medizinische Klinik B (Kardiologie, Pneumologie, Angiologie), Bremserstr. 79, 67063 Ludwigshafen, Germany.
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20
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Farwell DJ, Sulke AN. A randomised prospective comparison of three protocols for head-up tilt testing and carotid sinus massage. Int J Cardiol 2005; 105:241-9. [PMID: 16019088 DOI: 10.1016/j.ijcard.2004.10.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Accepted: 10/16/2004] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Head-up tilt testing is an important tool in the diagnosis of syncope. Several different protocols are in use. This study aimed to compare three different protocols in an unselected population of patients with recurrent unexplained syncope and to assess long-term outcome using conventional tilt-directed management or implantable loop recorder (Reveal Plus)-directed management, allowing evaluation of the sensitivity and specificity of the technique. METHODS Patients with recurrent unexplained syncope were randomized to one of three tilt protocols: Drug-free--70 degree tilt, 45 min, CSM at 5 and 45 min. GTN--70 degree tilt, 35 min, CSM at 5 min, 400 microg of glyceryl trinitrate spray administered sublingually at 20 min. Adenosine--70 degree tilt, 5 min, CSM when blood pressure is stable in upright position, adenosine bonus at 150 microg/kg after CSM. Tilts were terminated at the onset of syncope, when systolic BP reached 60 mm Hg, or in the presence of prolonged hypotension (> 3 min systolic BP < 80 mm Hg). Appropriate therapies were commenced according to the result of the tilt test. All patients without a definite indication for immediate cardiac pacing (asystolic tilt) were randomized to conventional management or ILR implantation. Recurrent syncopal events were compared to tilt outcome, allowing estimation of sensitivity and specificity. RESULTS Of 214 patients, aged 68+/-18 years, 55% were female, with a median of three previous syncopes. 13 patients received pacemakers due to asystolic syncope during tilt testing. The proportion of VASIS classification diagnoses was similar with each protocol; however more positive diagnoses resulted from the GTN protocol (p=0.0013). 47% of patients achieved a diagnosis with tilt testing. We were able to correlate a subsequent spontaneous syncope to tilt result in 36 patients (18%). Heart rate during a spontaneous event was similar to that obtained during tilt testing (+/- 10%) in 55% of cases. Sensitivities for combined protocols, adenosine, GTN, and drug-free protocols were 50%, 50%, 100%, and 21%, respectively. Specificities were 85%, 100%, 75%, and 71%, respectively. CONCLUSIONS A high diagnosis rate for unexplained syncope can be achieved with tilt testing. The GTN protocol resulted in significantly more diagnoses than the other compared protocols with good sensitivity and adequate specificity. Sensitivity of the drug-free tilt test was lower than drug-augmented tilt testing.
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Affiliation(s)
- D J Farwell
- Department of Cardiology, Eastbourne District General Hospital, King's Drive, Eastbourne, East Sussex, UK
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Becker A, Noachtar S, Reithmann C, Brandt T, Steinbeck G. [Syncope and epileptic seizures]. Internist (Berl) 2005; 46:994, 996-1000, 1002-5. [PMID: 16021407 DOI: 10.1007/s00108-005-1475-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Syncope is one of the most common symptoms leading to hospital admission. Thereby syncope can be induced by several diseases. It is crucial to detect underlying structural heart disease or high grade arrhythmias, as these are associated with an increased mortality. The careful history and physical examination can often give sufficient evidence to evaluate the origin of syncope. Additional examinations should only be applied selectively. In patients with structural heart disease the specific treatment should be initiated, in patients with cardiac arrhythmias the implantation of a pacemaker or ICD might be indicated. The most common neurally-mediated and orthostatic syncopes can often be treated successfully by physical training. Beside syncope epilepsy might be responsible for a transient loss of consciousness. Again careful history taking helps to differentiate between these two entities.
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Affiliation(s)
- A Becker
- Medizinische Klinik und Poliklinik I, Klinikum Grosshadern der Ludwig-Maximilians-Universität München.
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Abstract
There are many causes of syncope that include neurological (autonomic and non-autonomic), cardiac and psychiatric causes, amongst others. Disorders of the autonomic nervous system, either intermittent or fixed, are increasingly recognised as contributing to a large proportion of syncope. However, the majority of guidelines focus on cardiological and neurological evaluation in these disorders. In this overview we focus specifically on the role of autonomic evaluation. This has dual purposes; to aid the diagnosis and cause of syncope, and furthermore to provide information to understand the pathophysiological basis of syncope and thus improve management of such disorders.
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Affiliation(s)
- Christopher J Mathias
- Neurovascular Medicine Unit, Faculty of Medicine, Imperial College London at St Mary's Hospital, 2nd Floor, Queen Elizabeth the Queen, Mother Wing, Praed Street, London W2 1NY, UK.
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Bellard E, Fortrat JO, Schang D, Dupuis JM, Victor J, Lefthériotis G. Late Hemodynamic Changes During a Negative Passive Head-up Tilt Predict the Symptomatic Outcome to a Nitroglycerin Sensitized Tilt. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:89-96. [PMID: 15679637 DOI: 10.1111/j.1540-8159.2005.09250.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sublingual nitroglycerin is advocated to sensitize the passive 70 degrees head-upright tilt test (HUTT) of patients with unexplained syncope. We hypothesized that a detailed analysis of hemodynamic responses recorded during a negative HUTT could predict the outcome to a subsequent nitroglycerin sensitized HUTT (NTG-HUTT). METHODS Thirty-two patients (46 +/- 3 years, 17 males) with recurrent unexplained syncope but a negative HUTT were included. Heart rate, arterial blood pressure, and central hemodynamics assessed by transthoracic impedance (preejection and rapid left ventricular ejection time, slow ejection time, peak amplitude of first derivative, and cardiac index) were recorded during supine rest and 45 minutes HUTT. Changes from supine rest of the variables were retrospectively compared between patients with a negative (n = 15, NTG-HUTT(-)) and positive (n = 17, NTG-HUTT(+)) outcome to 10 minutes subsequent NTG-HUTT. RESULT Significant differences between groups were observed during the 15th-20th minutes (Italian protocol) and during the last 5 minutes of passive HUTT (Westminster protocol). The combination of cutoff values, determined by receiver operating curves, on hemodynamic variables changes during the last 5 minutes predicted the outcome to a NTG-HUTT with a sensitivity of 76% and a specificity of 87%. The cutoff values determined during 15th-20th minutes gave an attractive sensitivity (85%) but a too weak specificity (53%) to shorten the 45 minutes passive HUTT at 20 minutes. CONCLUSION Outcome to a NTG-HUTT can be reliably predicted by selected criteria determined from multiple hemodynamic variables recorded during a passive 70 degrees HUTT.
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Affiliation(s)
- Elisabeth Bellard
- Laboratoire de Physiologie, Faculté de Médecine, Angers Cedex, France
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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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Mittal S, Stein KM, Markowitz SM, Iwai S, Guttigoli A, Lerman BB. Single-stage adenosine tilt testing in patients with unexplained syncope. J Cardiovasc Electrophysiol 2004; 15:637-40. [PMID: 15175056 DOI: 10.1046/j.1540-8167.2004.03556.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION We previously have shown that a 3-minute single-stage adenosine tilt test has a diagnostic yield comparable to a two-stage protocol consisting of a 30-minute drug-free tilt followed by a 15-minute isoproterenol tilt. In this study, we sought to further define the clinical utility of adenosine tilt testing in patients with unexplained syncope by prospectively evaluating test specificity and determining predictors of a positive test response. METHODS AND RESULTS The specificity of single-stage adenosine tilt testing was determined using 30 control subjects. To determine the diagnostic yield of this protocol, adenosine tilts were performed in 129 patients with unexplained syncope. The adenosine tilt test protocol had high specificity (100%) but a low overall diagnostic yield (18%). However, the yield was affected significantly by age. In patients </=40 years of age, the tilt test was positive in 15 (41%) of 37 patients, which was significantly greater than the yield in patients between the ages of 41 and 64 years (6/41 patients [15%], P = 0.012) and those >/=65 years of age (2/41 patients [5%], P < 0.0001). CONCLUSION These data support single-stage adenosine tilt testing in patients </=40 years of age because the diagnostic yield of the test is maximal in this group and the test can be completed in </=3 minutes. Conversely, the diagnostic yield of adenosine tilt testing in patients >40 years of age is low, suggesting that the clinical utility of this protocol is limited in these patients.
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Affiliation(s)
- Suneet Mittal
- Department of Medicine, Division of Cardiology, Cornell University Medical Center, New York, New York 10021, USA.
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Nava S, Mont L, Silva RMFL, Rogel U, Osorio P, Bartholomay E, Berruezo A, Chueca E, Brugada J. Short Head-Up Tilt Test Potentiated with Oral Nitroglycerine:. Comparison with a Conventional Test Using Isoproterenol. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:1085-8. [PMID: 15305956 DOI: 10.1111/j.1540-8159.2004.00588.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Conventional tilt test protocols are time consuming and there is no consensus regarding the optimal duration of the test and the provocative drug to be used. This study evaluated the diagnostic power of a short nitroglycerine test against a conventional isoproterenol protocol. A cohort of 128 patients with unexplained syncope was studied. A group of 64 consecutive patients were tilted with a short nitroglycerine test consisting of a passive phase of 15 minutes and if this proved negative, 400 microg of sublingual nitroglycerin spray for a further 15 minutes. The control group consisted of 64 patients tilted with a conventional isoproterenol protocol with a passive phase of 30 minutes and a drug-challenge phase of 20 minutes. In the nitroglycerine protocol 39 (60.9%) patients showed a positive response versus 27(42.2%) in the isoproterenol group (P = 0.034). The duration of the protocol was 23.2 +/- 7.2 minutes in the nitroglycerine group versus 41.1 +/- 15.5 minutes with isoproterenol (P = 0.001). The time until syncope was 18.87 +/- 6.1 versus 29 +/- 18, respectively (P = 0.002). For evaluating unexplained syncope the short tilt test protocol with nitroglycerine is less time consuming, easier to perform, and has a higher rate of positive response than a conventional isoproterenol protocol.
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Affiliation(s)
- Santiago Nava
- Arrhythmia Section, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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Affiliation(s)
- Arnaud J J Aerts
- Department of Cardiology, Atrium Medisch Centrum Heerlen, the Netherlands.
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Delépine S, Prunier F, Lefthériotis G, Dupuis J, Vielle B, Geslin P, Victor J. 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; 90:488-91. [PMID: 12208407 DOI: 10.1016/s0002-9149(02)02519-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
It is unknown if the head-upright tilt test in patients who receive isoproterenol and nitroglycerin can identify different populations with vasovagal syncope. The aim of this study was to compare the positive or negative responses to passive tilt between isoproterenol- and nitroglycerin-sensitized upright tilt. Ninety-six patients referred for unexplained recurrent syncope underwent passive tilt (45 minutes at 70 degrees angle), which was then systematically followed, within the same session and in a random order, by a 20-minute tilt at a 70 degrees angle after administration of nitroglycerin (NTG-tilt) and 10-minute tilt at a 70 degrees angle with a continuous infusion of isoproterenol (ISO-tilt). NTG-tilt led to significantly more positive responses than passive tilt or ISO-tilt (55% vs 34% vs 42%, respectively). In the subgroup of patients with a positive response during passive tilt, the percentage of positive responses with NTG-tilt was significantly higher than with ISO-tilt (94% vs 67%). The agreement between NTG-tilt and ISO-tilt was very weak (Kappa coefficient 0.06). In the subgroup of patients with a negative response during passive tilt, the percentage of positive responses between NTG-tilt and ISO-tilt was similar (35% vs 29%). The agreement between NTG-tilt and ISO-tilt was good (Kappa coefficient 0.34). NTG-tilt led to a higher number of positive responses than ISO-tilt, especially when passive tilt outcome was positive. These 2 pharmacologic agents may identify 2 different subpopulations of patients because of their specific pharmacologic actions.
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Affiliation(s)
- Stéphane Delépine
- Department of Cardiology, University Hospital of Angers, Angers, France.
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Lacunza Ruiz J, García Alberola A, Sánchez Muñoz JJ, Martínez Sánchez J, Llamas Lázaro C, Barnés Martínez J, Valdés Chávarri M. [Head-up tilt test potentiated with nitroglycerin. What is the optimal duration of the test after administration of the drug?]. Rev Esp Cardiol 2002; 55:713-7. [PMID: 12113698 DOI: 10.1016/s0300-8932(02)76689-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES Numerous variations of the head-up tilt-table test potentiated with nitrates have been reported. After the administration of nitroglycerin, between 10 and 25 min of continued tilting have been recommended. The aim of this study was to assess the optimal duration of the pharmacological phase of the head-up tilt-table test potentiated with sublingual administration of nitroglycerin spray (NTG-TT). METHOD The records of 498 consecutive NTG-TT were reviewed. Our protocol consisted of a 20-min drug-free phase at a 60o angle. If syncope does not develop, 400 microgram of sublingual nitroglycerin spray is administered and the patient continues to be tilted for a further 25 min. The test results and time to a positive response were analyzed. RESULTS The result of NTG-TT was positive in 288 procedures, most of them after nitroglycerin administration (255, 88.5%). The mean time to a positive response was 10.7 6.7 and 5.0 2.4 min during the control and pharmacological phases respectively. Most positive responses were concentrated in the 3 to 5 min after drug administration. The time to syncope after nitroglycerin administration was over 10 min in 9 patients and 15 min in only 2 patients. CONCLUSIONS The duration of the pharmacological phase of NTG-TT using the described protocol can be reduced to 15 min without loss of sensitivity. A further reduction to 10 min would decrease the rate of positive responses by a small amount and might be considered clinically acceptable.
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Affiliation(s)
- Javier Lacunza Ruiz
- Servicio de Cardiología. Hospital Universitario Virgen de la Arrixaca. Murcia. Spain
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Del Rosso A, Bartoletti A, Bartoli P, Ungar A, Bonechi F, Maioli M, Ieri A. Methodology of head-up tilt testing potentiated with sublingual nitroglycerin in unexplained syncope. Am J Cardiol 2000; 85:1007-11. [PMID: 10760344 DOI: 10.1016/s0002-9149(99)00919-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Shortened head-up tilt testing (HUT) potentiated with sublingual nitroglycerin (60 degrees passive standing for 20 minutes followed, if negative, by 400 microg of sublingual nitroglycerin spray with the test continuing for another 20 minutes) differs from conventional nitroglycerin HUT for a shorter drug-free phase (20 vs 45 minutes). To compare the positivity rate of the 2 protocols, both tests were performed in a randomized sequence in 10 patients with unexplained syncope (study 1), and another 42 patients were randomly assigned either to conventional or to shortened nitroglycerin HUT (study 2). To evaluate the reproducibility of the shortened nitroglycerin HUT, another 38 patients with unexplained syncope underwent 2 consecutive tests within a 7+/-8 day interval (study 3). Finally, to evaluate the specificity of the test, 47 control subjects underwent shortened nitroglycerin HUT (study 4). Seven positive responses were observed during shortened nitroglycerin HUT, and there were 8 positive responses during conventional nitroglycerin HUT (p = NS) in the study 1 group. Fifteen positive (71%) responses, 5 negative responses, and 1 exaggerated response were observed during shortened nitroglycerin HUT; 16 positive (76%, p = NS vs. shortened nitroglycerin HUT), 3 negative, and 2 exaggerated responses were observed during conventional nitroglycerin HUT in the study 2 group. During the first test, 21 patients (55%) had a positive, 15 patients had a negative, and 2 patients had an exaggerated response in study group 3. During the second test, 15 positive (39%), 19 negative, and 4 exaggerated responses were observed. Thus, the reproducibility was 67% for a positive and 94% for a negative test. In control subjects, 2 positive (4%) responses, 38 negative, and 7 exaggerated responses were observed with a specificity of 96% in study group 4. In patients with unexplained syncope, shortened nitroglycerin HUT allowed a positivity rate similar to that of the conventional test. Moreover, the shortened test provided a high specificity and adequate reproducibility for both the positive and the negative responses.
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Affiliation(s)
- A Del Rosso
- Cardiology Division, Ospedale San Pietro Igneo, Fucecchio, Italy.
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