Abolish the Tilt Table Test for the Workup of Syncope!

Kulkarni, Nitin; Mody, Purav; Levine, Benjamin D.

doi:10.1161/circulationaha.119.043259

Cited by 23 publications

(20 citation statements)

References 5 publications

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“…Increasingly, laboratories that undertake TT are encouraged to include active stand testing in assessing patients. 9 , 10 However, active standing should not be confused with TT. While both introduce orthostatic stress, there are important physiological differences.…”

Section: Tilt-test Methodologymentioning

confidence: 99%

“…Recent criticisms by Kulkarni et al 9 suggest that, like any diagnostic test, TT can be inappropriately applied. Nevertheless, extensive experience, as well as evidence-based practice guideline recommendations, provides clear direction for its appropriate application and indicates when so TT is an important, effective diagnostic tool.…”

Section: Current Status Of Tilt Testingmentioning

confidence: 99%

“…1–4 Consequently, beginning in late 1980s, TT was incorporated into clinical assessment of syncope of unknown origin 1 as a method of triggering the vasovagal reflex in susceptible individuals by exposing them to controlled orthostatic challenge in a safe, monitored, clinical laboratory environment. 1 , 5–8 However, the clinical utility of TT has been criticised most recently by Kulkarni et al , 9 who promoted the less well-studied active stand test largely based on the presumption of lesser expense and, perhaps, greater convenience. In this review, while acknowledging TT limitations, we aim to offer counterpoint to the views of Kulkarni et al 9 by emphasizing both TT's well-documented clinical value and recommendations by multiple practice guidelines ( Table 1 ).…”

Section: Introductionmentioning

confidence: 99%

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Tilt testing remains a valuable asset

Sutton

Fedorowski

Olshansky

et al. 2021

European Heart Journal

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Head-up tilt test (TT) has been used for >50 years to study heart rate/blood pressure adaptation to positional changes, to model responses to haemorrhage, to assess orthostatic hypotension, and to evaluate haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. During these studies, some subjects experienced syncope due to vasovagal reflex. As a result, tilt testing was incorporated into clinical assessment of syncope when the origin was unknown. Subsequently, clinical experience supports the diagnostic value of TT. This is highlighted in evidence-based professional practice guidelines, which provide advice for TT methodology and interpretation, while concurrently identifying its limitations. Thus, TT remains a valuable clinical asset, one that has added importantly to the appreciation of pathophysiology of syncope/collapse and, thereby, has improved care of syncopal patients.

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Section: Tilt-test Methodologymentioning

confidence: 99%

Section: Current Status Of Tilt Testingmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Tilt testing remains a valuable asset

Sutton

Fedorowski

Olshansky

et al. 2021

European Heart Journal

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“…The role of TTT in diagnosing vasovagal syncope (VVS) has been debated [8][9][10][11]. The yield of a certain or highly likely diagnosis with history taking following an initial evaluation by hospital physicians and long-term follow-up as a reference may amount to 60%, with an accuracy of about 90% [12].…”

Section: To Obtain a Pathophysiological Correlate For Orthostatic Intmentioning

confidence: 99%

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness

et al. 2021

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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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“…Although a comprehensive history and physical examination including an electrocardiogram (ECG) is a good diagnostic tool, it is not always confirmatory and a TTT is often necessary, since the cause of syncope is multifactorial with the most common types listed in Table 1 2,3 . In a recent editorial, Kulkarni et al 6 state that a comprehensive history and physical examination is all that is necessary for the diagnosis of VVS and that a TTT is not essential and should be abolished. We believe that this recommendation is not valid and that the TTT is still a very useful test for the evaluation and diagnostic confirmation of VVS, despite some limitations 7 …”

Section: Introductionmentioning

confidence: 99%

The tilt table test is useful for the diagnosis of vasovagal syncope and should not be abolished

Chrysant

2020

J of Clinical Hypertension

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Abolish the Tilt Table Test for the Workup of Syncope!

Cited by 23 publications

References 5 publications

Tilt testing remains a valuable asset

Tilt testing remains a valuable asset

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness

The tilt table test is useful for the diagnosis of vasovagal syncope and should not be abolished

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