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Tilt-Table Testing

  • Author: James V Talano, MD, MBA; Chief Editor: Karlheinz Peter, MD, PhD  more...
 
Updated: Mar 17, 2016
 

Background

The tilt-table test is a simple, noninvasive, and informative test first described in 1986 as a diagnostic tool for patients with syncope of unknown origin.[1] It is usually performed in hospital electrophysiology departments with the endpoint of reproducing syncope and subsequent appropriate therapy.

The causes of syncope have been divided into 6 major categories, as listed below.[2] After a careful history and physical examination, tilt-table testing is particularly helpful in confirmation of the etiology of syncope dysfunction of the autonomic nervous system, encompassing primary or secondary dysautonomias, postural orthostatic tachycardia syndrome (POTS), and vasodepressor or vasovagal syncope. Other venues of investigation, such as a 12-lead electrocardiogram, orthostatic blood pressure readings, Holter/event recording, serum glucose and electrolytes, echocardiography, and psychiatric and/or neurology consultation should be considered prior to tilt-table testing to rule out malignant dysrhythmic, metabolic, cardiac mechanical, or psychological/neurological etiologies of syncope.[3]

The 6 major categories of syncopal etiologies [2]

Neurological disorders

Metabolic disorders

Mechanical heart disease

  • Global ischemia
  • Aortic dissection
  • Pulmonic dissection
  • Obstructive cardiomyopathy
  • Left atrial myxoma
  • Prosthetic valve dysfunction
  • Pulmonary embolus
  • Pulmonary hypertension

Cardiac arrhythmias/brady arrhythmias/tachyarrhythmias

  • Bradycardia/pauses
  • Sinus node dysfunction
  • AV conduction disease

Psychiatric disorders

  • Panic attacks
  • Hysteria

Autonomic Nervous System Dysfunction

  • Primary and secondary dysautonomias
  • Postural orthostatic tachycardia syndrome (POTS)
  • Postural orthostatic hypotension
  • Vasodepressor or vasovagal syncope
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Indications

Consider tilt-table testing in patients with signs or symptoms suggestive of orthostatic hypotension, vasodepressor or vasovagal syncope, postural orthostatic tachycardia, or when other causes of syncope have been eliminated. In general, consider tilt-table testing for patients with the following issues:

  • Hypotension (unexplained)
  • Tachycardia when standing
  • Pallor when upright
  • Orthostatic palpitations
  • Dizziness (unexplained)
  • Lightheadedness
  • History of frequent unexplained falls
  • History of episodes of fainting or loss of consciousness

The ACC expert consensus document for tilt-table testing including indications was first published in 1996.[4] The European Society of Cardiology formed a taskforce to update guidelines for the diagnosis and management of syncope in 2001, which was revised in 2009.[3] It includes indications for tilt-table testing with classes of recommendation and levels of evidence (see Table 1).

Table 1. European Society of Cardiology 2009 Indications for Tilt-Table Testing[3] (Open Table in a new window)

Recommendations Class level
Tilt table is indicated in the case of an unexplained single syncopal episode in high-risk settings (eg, occurrence of, or potential risk of physical injury or with occupational implications)or recurrent episodes in the absence of organic heart disease, after cardiac causes of syncope have been excluded IB
Tilt testing is indicated when it is of clinical value to demonstrate susceptibility to reflex syncope to the patientIC
Tilt testing should be considered to discriminate between reflex and orthostatic hypotensive syncopeIIaC
Tilt testing may be considered for differentiating syncope with jerking movement from epilepsyIIbC
Tilt testing may be indicated for evaluating patients with recurrent unexplained fallsIIbC
Tilt testing may be indicated for evaluating patients with frequent syncope and psychiatric diseaseIIbC
Tilt testing is not recommended for assessment of treatmentIIIB
Isoproterenol tilt testing is contraindicated in patients with ischemic heart diseaseIIIC
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Contraindications

Contraindications to tilt-table testing include the following:[3]

  • Coma
  • Feeble patient unable to stand
  • Lower extremity fractures
  • Severe anemia
  • Recent stroke (within seven days)
  • Recent myocardial infarction
  • Severe proximal cerebral or coronary arterial disease
  • Critical mitral or aortic stenosis
  • Left ventricular outflow tract obstruction
  • Hypotensive shock
  • Tachyarrhythmias
  • Severe metabolic acidosis
  • Electrolyte imbalance
  • End-stage renal failure
  • Severe heart failure
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Technical Considerations

Complication Prevention

Avoid invasive intra-arterial blood pressure monitoring during tilt-table testing because catheterization may provoke a vasovagal reaction. Use a manual sphygmomanometer or digital plethysmography.[5]

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Outcomes

Generally tilt-table testing is safe, but complications may occur related to decreased perfusion of the heart, including the following:

  • Electrocardiographic changes of transient myocardial ischemia with or without angina.
  • Vasospasm with isoproterenol administration.[6]
  • Occasionally, cardiac arrhythmias result in termination of the test, such as advanced atrioventricular block (second or third degree), severe bradycardia or pauses, atrial fibrillation, or tachyarrhythmias.

Complications may also occur related to decreased perfusion of the brain, including the following :

  • Seizures from prolonged hypotension (this is a transient phenomenon and not indicative of a seizure disorder)
  • Rarely, transient ischemic attacks or strokes occur.
  • Transient mental confusion can occur.
  • Patients may also experience nonspecific symptoms such as nausea or anxiety.
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Contributor Information and Disclosures
Author

James V Talano, MD, MBA MM, FACC, FAHA, Director of Cardiovascular Medicine, SWICFT Institute

James V Talano, MD, MBA is a member of the following medical societies: American College of Cardiology, Heart Failure Society of America, Society of Geriatric Cardiology, American Society of Nuclear Cardiology, American College of Chest Physicians, American Association for Physician Leadership, American College of Physicians, American Heart Association, American Society of Echocardiography

Disclosure: Nothing to disclose.

Coauthor(s)

Janet K Sparker, MS, PA-C Assistant Professor, Southwest Florida Physician Assistant Program, Nova Southeastern University; Physician Assistant, Certified, Private Cardiology Practice of James V Talano, MD, Southwest Institute of Cardiovascular Fitness and Testing

Disclosure: Nothing to disclose.

Chief Editor

Karlheinz Peter, MD, PhD Professor of Medicine, Monash University; Head of Centre of Thrombosis and Myocardial Infarction, Head of Division of Atherothrombosis and Vascular Biology, Associate Director, Baker Heart Research Institute; Interventional Cardiologist, The Alfred Hospital, Australia

Karlheinz Peter, MD, PhD is a member of the following medical societies: American Heart Association, German Cardiac Society, Cardiac Society of Australia and New Zealand

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

The authors gratefully acknowledge the contributions of Dr Fredrick Jaeger, Director, Cardiac Arrhythmia Monitoring Lab, Medical Director, Syncope Center, Cleveland Clinic to the development and writing of this article.

References
  1. Moya A. Tilt testing and neurally mediated syncope: too many protocols for one condition or specific protocols for different situations?. Eur Heart J. 2009 Sep. 30(18):2174-6. [Medline].

  2. Fogoros R. 2nd Ed. Electrophysiologic testing. Cambridge, MA: Blackwell Science; 1995.

  3. Moya A, Sutton R, et al. Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009 Nov. 30(21):2631-71. [Medline].

  4. Benditt DG, Ferguson DW, Grubb BP, Kapoor WN, Kugler J, Lerman BB. Tilt table testing for assessing syncope. American College of Cardiology. J Am Coll Cardiol. 1996 Jul. 28(1):263-75. [Medline].

  5. Goldman L, Braunwald E. Primary cardiology. Philadelphia, PA: WB Saunders; 19.

  6. Leman RB, Clarke E, Gillette P. Significant complications can occur with ischemic heart disease and tilt table testing. Pacing Clin Electrophysiol. 1999 Apr. 22(4 Pt 1):675-7. [Medline].

  7. Parry SW, Reeve P, Lawson J, Shaw FE, Davison J, Norton M. The Newcastle protocols 2008: an update on head-up tilt table testing and the management of vasovagal syncope and related disorders. Heart. 2009 Mar. 95(5):416-20. [Medline].

  8. Strickberger SA, Benson DW, Biaggioni I, Callans DJ, Cohen MI, Ellenbogen KA. AHA/ACCF scientific statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation In Collaboration With the Heart Rhythm Society. J Am Coll Cardiol. 2006 Jan 17. 47(2):473-84. [Medline].

  9. Barón-Esquivias G, Martínez-Rubio A. Tilt table test: state of the art. Indian Pacing Electrophysiol J. 2003. 3(4):239-52. [Medline]. [Full Text].

  10. Fouad-Tarazi F, Calcatti J, Christian R, Armstrong R, Depaul M. Blood volume measurement as a tool in diagnosing syncope. Am J Med Sci. 2007 Jul. 334(1):53-6. [Medline]. [Full Text].

  11. Guida P, Iacoviello M, Forleo C, Ferrara A, Sorrentino S, Balducci C. Prevalence, timing, and haemodynamic correlates of prodromes in patients with vasovagal syncope induced by head-up tilt test. Europace. 2009 Sep. 11(9):1221-6. [Medline].

  12. Brignole M. An Update on the Treatment of Vasovagal Syncope. HJC. 2004. 45:132-5. [Full Text].

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Patient undergoing upright tilt-table testing.
Tilt-table test.
Table 1. European Society of Cardiology 2009 Indications for Tilt-Table Testing[3]
Recommendations Class level
Tilt table is indicated in the case of an unexplained single syncopal episode in high-risk settings (eg, occurrence of, or potential risk of physical injury or with occupational implications)or recurrent episodes in the absence of organic heart disease, after cardiac causes of syncope have been excluded IB
Tilt testing is indicated when it is of clinical value to demonstrate susceptibility to reflex syncope to the patientIC
Tilt testing should be considered to discriminate between reflex and orthostatic hypotensive syncopeIIaC
Tilt testing may be considered for differentiating syncope with jerking movement from epilepsyIIbC
Tilt testing may be indicated for evaluating patients with recurrent unexplained fallsIIbC
Tilt testing may be indicated for evaluating patients with frequent syncope and psychiatric diseaseIIbC
Tilt testing is not recommended for assessment of treatmentIIIB
Isoproterenol tilt testing is contraindicated in patients with ischemic heart diseaseIIIC
Table 1. Classification of Positive Responses to Tilt Testing[9]
Type 1 -



Mixed



Heart rate falls at the time of syncope, but the ventricular rate does not fall to less than 40 beats/min-1 or falls to less 40 beats/min-1 for less than 10 s with or without asystole of less than 3 s. Blood pressure falls before the heart rate falls.
Type 2 -



Cardioinhibitory



A) Cardioinhibition without asystole: heart rate falls to a ventricular rate less than 40 beats/min-1 for more than 10 s, but asystole of more than 3 s does not occur before the heart rate falls.



B) Cardioinhibition with asystole: Asystole occurs for more than 3 s. Blood pressure falls with or occur before the heart rate fall.



Type 3 -



Vasodepressor



Heart rate does not fall more than 10% from its peak at the time of syncope.
 Exception 1. Chronotropic incompetence: No heart rate rise during the tilt testing (ie, less than 10% from the pre-tilt rate).
 Exception 2. Excessive heart rate rise: An excessive heart rate both at the onset of the position and throughout its duration before syncope (ie, greater than 130 beats/min-1).
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