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Tilt-Table Testing Technique

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

Approach Considerations

The tilt-table test involves placing a patient on a flat table with a foot support, then tilting the table upward for a period of time to observe changes in blood pressure and heart rate. The patient is initially positioned supine and horizontal on the table, then tilted by degrees to a completely vertical, upright position. During the study, blood pressure, heart rate, oxygen saturation, and cardiac rhythms are recorded and monitored for the end point of fainting, which indicates a positive tilt-test result.[7] The patient is also observed for signs and symptoms that would necessitate early termination of the study.

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Tilt-Table Testing

The following steps describe positioning and technique in tilt-table testing:[8]

  • Dress patient in hospital gown without restrictive binding around abdomen or legs.
  • Insert an intravenous catheter and start a maintenance IV fluid drip with 0.9% NaCl.
  • Place patient supine on tilt table and secure patient with protective straps to avoid falls.
  • Apply blood pressure, heart rate, oxygen saturation, and rhythm monitors and record baseline measurements.
  • Have the patient rest supine for 10 minutes.
  • Provide a room that is quiet, dim, and a comfortable temperature.
  • Raise tilt table up to 80°.
  • Record blood pressure, heart rate, and oxygen saturations every minute.
  • Tilt table upright for 20-45 minutes depending on protocol.
  • Record rhythm changes on ECG strip.
  • Decide if pharmacologic provocation with nitroglycerine after 5 minutes of tilt or isoproterenol after 20 minutes of tilt is needed to provoke a response.
  • Record any symptoms or signs observed.
  • Terminate tilt if systolic blood pressure falls below 70 mmHg, even if symptoms are not present.
  • Terminate tilt if patient faints, and return patient to supine position.
  • Place patient in reverse Trendelenburg position if blood pressure does not normalize.
  • Administer a 250-mL bolus of 0.9% NaCl for hypotension.
  • Record blood pressure and heart rate until back to baseline.
  • Disconnect patient and allow patient to sit in chair for 5 minutes.
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Test Results

If provocative pharmaceuticals such as isoproterenol or nitroglycerine are used, differentiate the expected pharmacological effects of the drug from an abnormal response.

If avoidance of pharmacologic testing is desired, such as in a patient with ischemic heart disease, proceed with an upright tilt for 45 minutes. If a fainting response does not occur, the test is negative.

A positive tilt-table test result may be described as mixed, cardio inhibitory, or vasodepressor (see Overview).[9]

Classification of positive responses to tilt testing

One particular problem with tilt-table testing is the plethora of protocols with differing sensitivity, which can make reproduction of results unreliable. The reliability and accuracy of tilt-table studies is improved when combined with hemodynamic and volume measurements.[10] These procedures include nuclear hemodynamic studies, which can be performed in conjunction with an outpatient tilt-table test. They can be repeated at follow-up visits to assess response to treatment. Autonomic reflex testing, which includes the combination of vascular reactivity measures with the tilt-table test, can also be performed to improve the sensitivity of tilt-table testing.[10] However, a criterion standard for positivity remains to be. Adherence to positivity criteria is essential (see Table 2). If hemodynamic changes occur without syncope, the test is a false positive.[7]

Table 1. Classification of Positive Responses to Tilt Testing[9] (Open Table in a new window)

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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Definitions of Key Terms

Dysautonomias, primary

Deficiency of mechanisms that increase α- and β- adrenergic tone as a result of baroreceptor stimulation to compensate for a decrease of venous blood return to the heart

HUT

Abbreviation for head-up tilt test

Neurally mediated hypotension

Reduction in systolic blood pressure 25 mmHg from baseline supine values, sustained for at least 1 minute, with no associated increase in heart rate, and accompanied by symptoms of presyncope

Neurocardiogenic syncope

Acute hypotension with or without bradycardia

Orthostatic (postural) hypotension

Greater than 20-30 mmHg drop in systolic blood pressure plus a greater than 10 mmHg drop in diastolic blood pressure: Orthostatic hypotension is a common cause of a temporary loss of consciousness or feelings of lightheadedness, which results from changing body position from a supine or sitting position to a more vertical or upright position. Normally, blood tends to pool in the lower extremities due to gravity whenever a person stands up, potentially reducing the amount of blood available to return to the heart or brain.

The sympathetic nervous system regulates blood vessel tone by modulating nerve traffic to lower extremity blood vessels. The arterial and venous circulations compensate for pooling by constricting; thus redirecting blood flow from the leg veins back toward the heart. However, poor sympathetic tone to the lower extremity blood vessels can cause the mechanisms of arterial and venous constriction to fail, resulting in a disproportionate pooling of blood in the legs, instead of returning blood to the circulation, resulting in less oxygen supplied to the brain and heart. As a result, a person feels lightheaded and may even faint.

Postural orthostatic tachycardia syndrome (POTS)

The occurrence of orthostatic symptoms in association with either a 30 beats/ minute increase in heart rate from baseline within 10 minutes of being tilted upright, sustained for 1 minute or more, or a heart rate of higher than 120 beats/ minute in the same period

Presyncope

The presence of premonitory symptoms and signs of imminent syncope such as severe weakness, lightheadedness, nausea, or diaphoresis

Syncope

Pan-cerebral hypoperfusion accompanied by a lack of postural tone and unconsciousness without focal neurological deficit

Vasodepressor syncope

Abrupt drop in blood pressure with symptoms

Vasovagal syncope

Abrupt drop in blood pressure and heart rate with symptoms: The hallmark of vasovagal syncope is the occurrence of one to several symptoms either before, during, and immediately after a brief loss of consciousness. Symptoms are varied, and may include nausea, flushing, headache, vertigo, palpitations, and asthenia.[11]

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Web Links

See the list below:

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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 I B
Tilt testing is indicated when it is of clinical value to demonstrate susceptibility to reflex syncope to the patient I C
Tilt testing should be considered to discriminate between reflex and orthostatic hypotensive syncope IIa C
Tilt testing may be considered for differentiating syncope with jerking movement from epilepsy IIb C
Tilt testing may be indicated for evaluating patients with recurrent unexplained falls IIb C
Tilt testing may be indicated for evaluating patients with frequent syncope and psychiatric disease IIb C
Tilt testing is not recommended for assessment of treatment III B
Isoproterenol tilt testing is contraindicated in patients with ischemic heart disease III C
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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