Tilt Testing Remains a Valuable Asset

Richard Sutton; Artur Fedorowski; Brian Olshansky; J. Gert van Dijk; Haruhiko Abe; Michele Brignole; Frederik de Lange; Rose Anne Kenny; Phang Boon Lim; Angel Moya; Stuart D. Rosen; Vincenzo Russo; Julian M. Stewart; Roland D. Thijs; David G. Benditt

Disclosures

Eur Heart J. 2021;42(17):1654-1660. 

In This Article

Abstract and Introduction

Abstract

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.

Graphical Abstract

Introduction

Head-up tilt test (TT) has been used for more than half a century by physiologists and physicians to study heart rate and blood pressure adaptation to positional changes, to model responses to haemorrhage, to assess characteristics of orthostatic hypotension (OH), and to evaluate haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. During these studies, some subjects experienced total or near-total transient loss of consciousness (TLOC) due to hypotension induced by TT (often accompanied by bradycardia/asystole).[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).

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