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

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.

New hemodynamic criteria to separate classical orthostatic hypotension from vasovagal syncope

“…In clinical practice, the presence of emotional triggers for VVS should exclude any confusion with cOH, but in such cases, there usually is no need to perform TTT 1,10 . Even so, it is unknown whether spontaneous emotional VVS has the same hemodynamic features as orthostatic VVS we described here.…”

“…We did not compare TTT results with other tests that can be applied in cOH, such as the Valsalva test or the active stand test 10 . The active stand test usually lasts shorter than a TTT, and so is less likely to evoke VVS, but this is not impossible.…”

“…. The tilt table test (TTT) plays an important role in the work‐up of those with unexplained OI or TLOC 1,7–10 …”

Long-Term COVID 19 Sequelae in Adolescents: the Overlap with Orthostatic Intolerance and ME/CFS

“…We recommend the following instruments in children and adolescents, all of which have the advantage of being brief and imposing only a minimal cognitive burden on patients: •Functional Disability Inventory [ 118 ] •Pediatric Quality of Life Inventory (Peds QL) [ 119 ] (Questionnaires exist for both the patient and an adult proxy, but a direct report from the patient is important) •Peds QL Multidimensional Fatigue Scale [ 120 ] •Wood Mental Fatigue Inventory [ 121 ] •Hospital Anxiety and Depression Scale [ 122 ] or Beck Depression Inventory [ 123 ] Our recommended battery for neuropsychologic evaluation that can be performed in person or via telehealth has been published elsewhere [ 17 •] Orthostatic testing In all individuals with chronic fatigue, and at this stage of the investigation of long COVID, we recommend orthostatic testing of at least 10 min duration. This can be accomplished using either a passive standing test or a head-up tilt test Passive standing test [ 95 ] Laboratory head-up tilt table test [ 124 , 125 ] 5 min supine—> 10 min of quiet standing with the upper back against the wall and heels 2–6 inches away from the wall—> 2 min supine Heart rate and blood pressure were measured during a 70-degree head-up tilt 10-min tests are sufficient for diagnosing POTS and OH Prolonged testing of 40–45 min is usually required to identify neurally mediated hypotension or delayed OH Record Each minute Heart rate and blood pressure *To calculate the HR increment between lowest supine and peak standing, select the lowest supine HR value from either the 5 min pre-test or the 2 min post-test The end of the first supine phase and each minute standing Symptoms on a 0–10 scale (0 = no symptom, 10 = worst severity) Presence of acrocyanosis …”

Rethinking neurological attitudes towards vasovagal syncope: The European Federation of Autonomic Societies (EFAS) recommendations regarding tilt table testing

“…The recent recommendations regarding tilt table testing (TTT) from the European Federation of Autonomic Societies (EFAS) provides a rationale and evidence base for the use of TTT in conditions that cause transient loss of consciousness (TLOC) and insights into current attitudes regarding TTT [1,2]. Historically, only relatively few neurologists took an interest in clinical disorders of the autonomic nervous system and often focused their attention toward debilitating but rare causes of neurogenic orthostatic hypotension.…”