Randomized Prospective Comparison of Two Protocols for Head-up Tilt Testing in Patients with Normal Heart and Recurrent Unexplained Syncope (original) (raw)
Related papers
The American Journal of Cardiology, 1995
This study was undertaken to assess the value of sublingual nitroglycerin administration during u as a simple practical test for the diagnosis o P right tilt vasovagal syncope. To this purpose, 235 patients with syncope of unknown origin and no evidence of organic heart disease (110 men, mean age 52 f 20 years) and 35 asymptomatic control subjects underwent head-up tilt testing with nitroglycerin challenge. Patients and subjects were tilted at 60" for 45 + 20 minutes; the initial 45 minutes were without medication and the final 20 minutes after 300 pg of sublingual nitroglycerin. During the drug-free phase of the test, 59 patients (25%) and no controls had a positive response. After drug administration, a positive response (syncope in associa-I n recent years head-up tilt testing has gained great popularity as a means of diagnosing vasovagal syn-c0pe.l The reported sensitivity and specificity of headup tilt without pharmacologic provocation range from 32% to 74% (mean 47%) and from 90% to 100% (mean 95%), respectively.2-g The addition of isoproterenol to head-up tilt increases the test sensitivity up to 87%,'O but decreases its specificity to values between 55% and 100% (mean 76%).6,1o-" This has prompted the use of other drugs as provocative agents during upright tilt.14-16 In a previous study,16 we reported on the usefulness of nitroglycerin infusion in conjunction with head-up tilt; the test proved to be more sensitive and feasible than the isoproterenol test, and equally specific, but the protocol used was quite complicated and time-consuming.16 The aim of the present study was to assess the diagnostic value of a new simplified, more rapid and practical protocol for the nitroglycerin test, consisting of sublingual administration of the drug after an initial period of conventional unmedicated head-up tilt.
Revista portuguesa de cardiologia : orgão oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology
The importance of head-up tilt testing has been demonstrated in the evaluation of patients with unexplained syncope. In elderly patients, the prevalence of syncope increases, is associated with a worse outcome and frequently requires several complementary tests. To evaluate the utility of head-up tilt testing with sublingual nitroglycerin as a provocative agent, in elderly patients with unexplained syncope. We studied 46 consecutive patients aged >65 years (74 +/- 6 years, 56.5% female) with unexplained syncope. In 25 patients (54%), we found no cardiac anomaly. The remaining patients had hypertensive (14 patients) or ischemic (7 patients) heart disease. The protocol included carotid sinus massage in decubitus and after passive orthostatism. Tilt testing was performed with continuous electrocardiographic and blood pressure monitoring, at a 70 degrees tilt for 20 minutes. In the absence of syncope, we administered 500 mcg of nitroglycerin with an additional 20 minutes monitoring. ...
Europace, 2000
Head-up tilt testing potentiated by sublingual nitroglycerin (NTG), advocated by an Italian group, is a simple and safe but still not a standardized, diagnostic tool for the investigation of syncope. In fact, owing to its rapid spread, the original protocol received, often arbitrarily, many subsequent modifications. We now define the best methodology of the test on strictly evidence-based criteria as: stabilization phase of 5 min in the supine position; passive phase of 20 min at a tilt angle of 60 degrees; provocation phase of further 15 min after 400 g NTG sublingual spray. Test interruption is made when the protocol is completed in the absence of symptoms, or there is occurrence of syncope, or occurrence of progressive (>5 min) orthostatic hypotension. We intend that this protocol, named by us as 'The Italian Protocol', will be accepted as the standard methodology of the tilt test potentiated by sublingual nitrates.
Diagnostic utility of the head-up tilt test in syncope and the related complications
2017
Background: Recurrent syncope is a distressing symptom in which the cause may remain undetermined. A definitive diagnosis may help the patients to lead a normal life and avoid the unnecessary risk to their lives. Objective: To evaluate the effectiveness and safety of Head up Tilt Test (HUTT) in patients with undiagnosed syncope and to detect and follow up any complications arising out of the procedure. Material and methods: The head up tilt table test was performed in department of cardiology. 72 patients with a history of syncope or presyncope underwent upright tilt table testing to exclude vasovagal syncope, with baseline tilt and if negative followed by progressively increasing doses of isoprenaline infusion. 70° tilt was used and continuous heart rate and non-invasive BP recordings were made every 2 minutes or earlier when symptomatic. Results: The mean age of the patients was 48±16 years. None of the patients had carotid sinus hypersensitivity. Forty-five patients (62.5%) were ...
Elderly patients with unexplained syncope: What should be considered a positive tilt test response?
Autonomic Neuroscience, 2006
Introduction: Syncope is a common problem and can lead to serious consequences in the elderly. Tilt test is useful to investigate recurrent syncope, but few studies have investigated the hemodynamic responses of this population to tilt test. Objective: To describe the tilt test responses of elderly patients with recurrent syncope of unknown origin and to determine the occurrence of altered cardiovascular autonomic function in a subset of those with the diagnosis of dysautonomic pattern to the tilt test. Methods: Elderly patients (n = 165; > 60 years old) who sought medical assistance because of recurrent syncope during 18 months were initially enrolled and submitted to a two-stage, nitroglycerin-potentiated tilt test. A subset of patients who presented with dysautonomic response to tilt test performed clinical autonomic tests. Results: The most frequent cause of syncope during tilt test was the dysautonomic pattern (43%), followed by mixed type neurocardiogenic syncope (35%). Most patients who remained asymptomatic during tilt test showed clear abnormal hemodynamic response during the exam. Conclusion: Autonomic dysfunction, which can be found during tilt test, is probably an important cause of syncope in the elderly, regardless of the occurrence of symptoms during the tilt test.
Methodology of head-up tilt testing potentiated with sublingual nitroglycerin in unexplained syncope
The American Journal of Cardiology, 2000
Shortened head-up tilt testing (HUT) potentiated with sublingual nitroglycerin (60؇ passive standing for 20 minutes followed, if negative, by 400 g 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 exagger-ated 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.
…, 2008
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 mg. 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.
Use of nitroglycerin in the active phase of tilt testing: is there a difference in elderly patients?
Revista portuguesa de cardiologia : orgão oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology, 2007
The importance of tilt testing has been demonstrated in the evaluation of patients with syncope of unknown cause, and it is the gold standard technique for the diagnosis of neurocardiogenic syncope, particularly with the use of pharmacological provocative agents to improve diagnostic accuracy. Stimulation with sublingual nitroglycerin is generally well tolerated and increases test sensitivity, shortening the test duration; this also allows the test to be applied in elderly patients. To evaluate, in a population referred for syncope of unknown etiology, the value of tilt testing with sublingual nitroglycerin and to compare the responses obtained in elderly and younger patients. We studied 158 patients who underwent tilt testing using nitroglycerin as a provocative agent. We compared patients aged <65 years (Group A, n=74) and > or =65 years (Group B, n=84). Tilt testing was performed according to the Italian protocol, with continuous monitoring of the electrocardiogram and bloo...
Diagnostic value of the head-up tilt test and the R-test in patients with syncope
Heart International, 2006
The diagnostic value of the head-up tilt test (HUTT) in discovering vasovagal syndrome depends on the pre-test probability. An accurate anamnesis and clinical examination screens the patients indicated for the HUTT. In patients with unexplained syncope, the R-test is an alternative procedure to discover its cause. In our study, we evaluated the diagnostic significance of the HUTT in a group of 211 patients and of the R-test in a subgroup of 45 patients with negative HUTT results and with negative traditional Holter ECG monitoring (24 hr). (Heart International 2006; 3-4: 171-7)