Usefulness of tilt test–induced patterns of heart rate and blood pressure using a two-stage protocol with glyceryl trinitrate provocation in patients with syncope of unknown origin

doi:10.1016/S0002-9149(99)00413-0

The American Journal of Cardiology

Volume 84, Issue 6, 15 September 1999, Pages 665-670

https://doi.org/10.1016/S0002-9149(99)00413-0 Get rights and content

Abstract

This study assesses the vasovagal collapse pattern changes, i.e, heart rate (HR) and arterial blood pressure (BP) with a 2-stage tilt-test protocol using glyceryl trinitrate (GTN) provocation. With use of the 45-minute 60° head-up Westminster protocol, 102 consecutive patients were studied. Sublingual GTN 300 μg was given to those with a negative passive tilt. Heart rate and BP patterns were classified according to the Vasovagal International Study classification (VASIS) and then compared between those with a positive passive tilt and those with a positive tilt after having been given GTN. Twelve patients did not tolerate tilt testing, and 16 had a negative response despite taking GTN. Thirty-five patients (20 women and 15 men, mean age 45 ± 21 years [mean ± SD]) did not take GTN and 38 (26 women and 12 men, mean age 53 ± 22 years) had positive passive test results. When comparing the VASIS classification between the 2 groups, results showed: type 1, mixed BP and HR decreased without severe bradycardia (31% [passive] vs 54% [with GTN], p = NS); type 2A, BP decreased before HR decreased (20% vs 22%, p = NS); type 2B, HR decreased before or coincident with BP (34% vs 8%, p = 0.003); type 3, BP decreased without HR decrease (9% vs 0%, p = NS); exception 1, chronotropic incompetence (0% vs 13%, p = 0.026); and exception 2, excessive HR increase (6% vs 3%, p = NS). Thus, GTN use increases frequency of positive results from 34% to 73%. Older people with chronotropic incompetence, who may benefit from pacing, were identified. In younger people there was an increase in those with cardioinhibition.

Section snippets

Study population

One hundred two consecutive patients with syncope of unknown origin and no evidence of organic heart disease were included in the study. Of these patients, 43 were men and 59 were women (mean age ± SD 52 ± 21 years [range 12 to 84]). Patients were diagnosed as having unexplained syncope if no cause was found after a standard diagnostic evaluation. This included a careful history and physical examination, full clinical neurologic assessment, routine laboratory tests, supine and orthostatic BP

Results

Of the 102 patients, 12 did not tolerate tilt testing (age 69 ± 14 years, 8 women). Thirty-five were positive with passive (nonmedicated) tilt alone (age 45 ± 21 years, 20 women). Fifty-five were given GTN; of these 38 were positive (age 53 ± 22 years, 26 women). Thus, 16 remained negative despite administration of GTN. The addition of GTN increased the number of positive tilts from 35 (34%) to 73 (72%) patients.

Figure 7 summarizes the distribution of the VASIS HR and BP patterns of the 2

VASIS classification

Previous classifications have been an arbitrary and simplistic division into cardioinhibitory and vasodepressor groups solely based on minimum HR during an attack.16 The VASIS classification10 was founded on the possible therapeutic use of a pacemaker in the belief that an absence from bradycardia would preclude any benefit from pacing.

Effect of using a GTN provocation stage

The use of GTN provocation increases the yield of positive results from 34% to 72%. The remaining 28% was composed of the 12% who did not tolerate tilting and

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Patients with post-acute sequela of COVID-19 (PASC) often report symptoms of orthostatic intolerance and autonomic dysfunction. Numerous case reports link postural orthostatic tachycardia syndrome (POTS) to PASC. No prospective analysis has been performed.
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We performed a prospective, observational evaluation of patients with PASC complaining of poor exertional tolerance, tachycardia with minimal activity or positional change, and palpitations. Exclusion criteria included pregnancy, pre-PASC autonomic dysfunction or syncope, or another potential explanation of PASC symptoms. All subjects underwent HUTT.
Twenty-four patients with the described PASC symptoms were included. HUTT was performed a mean of 5.8 ± 3.5 months after symptom onset. Twenty-three of the 24 had orthostatic intolerance on HUTT, with 4 demonstrating POTS, 15 provoked orthostatic intolerance (POI) after nitroglycerin, 3 neurocardiogenic syncope, and 1 orthostatic hypotension. Compared with those with POTS, patients with POI described significantly earlier improvement of symptoms.
This prospective evaluation of HUTT in patients with PASC revealed orthostatic intolerance on HUTT suggestive of autonomic dysfunction in nearly all subjects. Those with POI may be further along the path of clinical recovery than those demonstrating POTS.
Tilt testing and what you should know about it - Experience with 835 consecutive patients with syncope of unknown origin
2018, International Journal of Cardiology
Numerous tilt testing protocols with and without a preceding passive phase or the administration of nitrates have already been investigated. However, a truely standardized method for the investigation does not yet exist.
A total of 835 consecutive patients who underwent tilt testing between January 2005 and March 2015 were included in this study. Results of a passive tilt test (PTT), a nitrate-stimulated tilt test (NSTT) with a preceding passive phase of 20 min, or an early nitrate-stimulated tilt test (ENSTT) without a preceding passive phase were compared and analyzed retrospectively in 735 patients. In addition, a further 100 consecutive patients were prospectively randomized 1:1 to compare NSTT and ENSTT. In the retrospective analysis, 38% of the patients in the ENSTT group had a positive test response compared with 45% in the NSTT group and only 27% in the PTT group (p = 0.0002). In the prospective study, 34% of the patients had a positive test response in the ENSTT group compared with 42% in the NSTT group (p = 0.537). The mean duration to a positive test response was significantly shorter in the ENSTT group (retrospective and prospective p < 0.001). The nitrate-stimulated groups did not differ significantly with respect to the hemodynamic characteristics of a positive test response (retrospective: p = 0.773; prospective: p = 0.086).
Due to the rate of positive test response being comparable to other protocols and its significantly shorter test duration, nitrate-stimulated tilt testing without a preceding passive tilt test may be favored for use in a busy clinical practice.
The Role of the Syncope Management Unit
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Citation Excerpt :
Since its seminal description, it has been used to assess OT in patients with syncope of unknown cause, as well as in healthy subjects to study postural cardiovascular reflexes.57–66 Tilting protocols comprise 3 categories: passive tilt, passive tilt accompanied by pharmacologic provocation (sublingual nitrate63,65,68–70 or, less commonly, isoprenaline66,67,70), and passive tilt with combined lower body negative pressure. The main drawback of HUTT is its inability to invoke presyncope in all individuals undergoing the test, and corresponding low sensitivity.
The role of the syncope management unit
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Syncope in the elderly: An update
2013, Journal of Clinical Gerontology and Geriatrics
Citation Excerpt :
In carefully selected cases in which the suspicion of ischemic syncope is very strong (e.g., in the presence of several risk factors for coronary artery disease and in the absence of other plausible causes of syncope) coronary angiography may be indicated.1 When the initial investigation, however, oriented towards a neurally-mediated syncope, as well as when the first-level tests are negative, the diagnostic procedure involves the carotid sinus massage in supine and standing positions, the Tilt Table Test (TTT)14 and, in selected cases, ambulatory monitoring of blood pressure over 24 hours, which is especially useful in the case of postprandial or night hypotension. Carotid sinus massage should be performed only by an experienced physician with electrocardiogram control and after objective and/or sonographic exclusion of carotid atherosclerosis.
Syncope in the elderly is an extremely prevalent clinical condition characterized by high mortality and presence of recurrences. The diagnosis of syncope in the elderly is sometimes difficult and multidimensional geriatric assessment should be carefully administered. Diagnostic algorithms should be applied with attention, although unknown syncope is still frequent. The therapeutic approach to syncope in the elderly is complicated by the high prevalence of neurally-mediated syncope, in which the therapeutic approach is still unknown. The establishment of a “Syncope Unit” has certainly improved the diagnostic-therapeutic approach to patients with syncope, especially in old age where the management is extremely difficult.
Syncope
2008, Handbook of Clinical Neurology
This chapter focuses on cardiac causes for syncope, in particular arrhythmic and neurocardiogenic syncope and their diagnosis and management. The cardiovascular causes for syncope include mechanical or structural heart disease, such as aortic stenosis or hypertrophic obstructive cardiomyopathy, cardiac arrhythmias, and neurally mediated syncope. The first step in the investigation of syncope is to accurately separate benign non-life-threatening causes such as vasovagal syncope from malignant, life-threatening causes such as ventricular arrhythmias. In general, investigations in syncope can be categorized into three tiers: tier 1(investigations immediately postsyncope), tier 2 (provocative tests), and tier 3 (association of an event with cardiac rhythm monitoring). The data presented in the chapter provides a concise framework for an approach to investigate and diagnose syncope. A management plan is devised that incorporates lifestyle measures to avoid syncope and pharmacological or device management to treat and prevent syncope. Recent advances in the area of long-term rhythm monitoring have enabled better understanding of cardiac syncope and its response to treatment.

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Arrhythmias and Conduction DisturbancesUsefulness of tilt test–induced patterns of heart rate and blood pressure using a two-stage protocol with glyceryl trinitrate provocation in patients with syncope of unknown origin

Abstract

Section snippets

Study population

Results

VASIS classification

Effect of using a GTN provocation stage

Am J Cardiol

J Am Coll Cardiol

Am J Med

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Head-up tilta useful test for investigation unexplained syncope

Lancet

Tilt table testing for evaluation of neurally mediated (neurocardiogenic) syncoperationale and proposed protocols

PACE

Arrhythmias and Conduction Disturbances
Usefulness of tilt test–induced patterns of heart rate and blood pressure using a two-stage protocol with glyceryl trinitrate provocation in patients with syncope of unknown origin