'The Italian Protocol': a simplified head-up tilt testing potentiated with oral nitroglycerin to assess patients with unexplained syncope

Bartoletti, Angelo; Alboni, Paoló; Ammirati, Fabrizio; Brignole, Michele; Rosso, Attilio Del; Manzillo, Giovanni Foglia; Menozzi, Carlo; Raviele, Antonio; Sutton, Richard

doi:10.1053/eupc.2000.0125

Cited by 252 publications

(170 citation statements)

References 17 publications

Supporting

Mentioning

162

Contrasting

Unclassified

Order By: Relevance

“…[3][4][5] Our previous study demonstrated that individuals with PPS had longer periods of apparent TLOC and were more likely to have their eyes closed during apparent TLOC than those with VVS.…”

Section: Methodsmentioning

confidence: 99%

Tilt-induced vasovagal syncope and psychogenic pseudosyncope

et al. 2015

View full text Add to dashboard Cite

Objective: To describe the combination of tilt-induced vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) and aid its clinical recognition. Methods:We identified people with tilt-induced VVS/PPS from 2 tertiary syncope referral centers.For each case, 3 controls with tilt-induced VVS were selected at random from the same center. Clinical characteristics were compared between both groups adjusting for multiple comparisons. Conclusions: VVS/PPS presents with a complex phenotype. High attack frequency, delayed recovery of consciousness, apparent loss of consciousness .1 minute, ictal eye closure, atypical triggers, and the absence of prodromes may serve as indicators that PPS coincides with VVS. Transient loss of consciousness (TLOC) is a frequent presentation, with vasovagal syncope (VVS) as the most common cause.1 Establishing the cause of TLOC can be difficult, especially when individuals present with 2 conditions simultaneously. The most reliable diagnosis of TLOC is obtained if appropriate pathophysiologic data are recorded during an attack recognized as typical by the individual. Blood pressure (BP), heart rate (HR), or both are low during VVS, but tend to be high during psychogenic pseudosyncope (PPS). 2 We previously noted that PPS either preceded or followed VVS in 12 out of 800 tilt-table tests, a pattern we label here as VVS/ PPS.2 This parallels the situation of psychogenic epileptic seizures (PNESs), which are also found more often in people with epileptic seizures. [3][4][5] Our previous study demonstrated that individuals with PPS had longer periods of apparent TLOC and were more likely to have their eyes closed during apparent TLOC than those with VVS.2 A sudden head drop or sliding down the tilt table was more frequent in individuals with PPS, whereas those with VVS were more likely to exhibit jerking movements. People with VVS/PPS may present with a mixture of the 2 sets of features, but this has not yet been described. Early recognition of VVS/PPS is important to avoid excessive testing. VVS features are probably better known than those of PPS. This

show abstract

Section: Methodsmentioning

confidence: 99%

Tilt-induced vasovagal syncope and psychogenic pseudosyncope

et al. 2015

View full text Add to dashboard Cite

show abstract

“…The aim of tilt-table testing is the provocation of an episode of apparent TLOC. 3,14 When patients stated specific triggers for their events, other provocative maneuvers were occasionally used. 10 A technician and a neurology resident were always present.…”

mentioning

confidence: 99%

The semiology of tilt-induced psychogenic pseudosyncope

Tannemaat

Niekerk²,

Reijntjes³

et al. 2013

Neurology

View full text Add to dashboard Cite

Objectives: To provide a detailed semiology to aid the clinical recognition of psychogenic pseudosyncope (PPS), which concerns episodes of apparent transient loss of consciousness (TLOC) that mimic syncope. Methods:We analyzed all consecutive tilt-table tests from 2006 to 2012 showing proven PPS, i.e., apparent TLOC had occurred without EEG changes or a decrease in heart rate (HR) or blood pressure (BP). We analyzed baseline characteristics, video data, EEG, ECG, and continuous BP measurements on a 1-second time scale. Data were compared with those of 69 cases of tilt-induced vasovagal syncope (VVS).Results: Of 800 tilt-table tests, 43 (5.4%) resulted in PPS. The majority (74%) were women. The median duration of apparent TLOC was longer in PPS (44 seconds) than in VVS (20 seconds, p , 0.05). During the event, the eyes were closed in 97% in PPS but in only 7% in VVS (p , 0.0001). A sudden head drop or moving down the tilt table was more common in PPS than in VVS (p , 0.01), but jerking movements occurred more frequently in VVS (p , 0.0001). In PPS, both HR and BP increased before and during apparent TLOC (p , 0.0001).Conclusions: PPS is clinically distinct from VVS and can be diagnosed accurately with tilt-table testing and simultaneous EEG monitoring. Compared with VVS, eye closure during the event, long periods of apparent TLOC, and high HR and BP are highly specific for PPS. Improved understanding of the semiology of PPS as a clinical entity is vital to ensure accurate diagnosis. Neurology â 2013;81:752-758 GLOSSARY BP 5 blood pressure; DBP 5 diastolic blood pressure; HR 5 heart rate; PNES 5 psychogenic nonepileptic seizure; PPS 5 psychogenic pseudosyncope; SBP 5 systolic blood pressure; sMAP 5 smoothed mean arterial pressure; TLOC 5 transient loss of consciousness; VVS 5 vasovagal syncope.Transient loss of consciousness (TLOC) is the reason for approximately 3% of all emergency department visits. 1 The most common major causes of apparent TLOC are syncope, epileptic seizures, and psychogenic events. [2][3][4] The pathophysiology of psychogenic and somatic apparent TLOC is different, but they can be difficult to distinguish clinically.Psychogenic apparent TLOC bears various labels. When episodes involve pronounced movements, they resemble epilepsy and are frequently labeled psychogenic nonepileptic seizures (PNES). 5 Episodes without pronounced movements resemble syncope and are generally labeled psychogenic pseudosyncope (PPS). 3 PNES and PPS are probably manifestations of the same underlying psychiatric disorder, but their different presentation has important consequences for diagnosis. PNES is relatively well known, with a reported prevalence of up to 30% in patients in epilepsy clinics. 5 In contrast, PPS is rarely mentioned in the literature on syncope, and the reported prevalence of PPS in those analyzed for presumed syncope is lower, ranging from 0% to 8%. [6][7][8]

show abstract

“…During scheduled tilt table tests based on a standardized protocol [10] HR and PATs were extracted from simultaneously acquired electrocardiogram (ECG) and the finger photoplethysmogram (PPG) measured with a Philips MP50. PAT is defined as time span between the ECG-R-peak and pulse onset (PATfoot) or pulse maximum (PATtop) in a peripheral photo-plethysmography (PPG) signal [4].…”

Section: Experimental Methodsmentioning

confidence: 99%