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


Eur Heart J. 2021;42(17):1654-1660. 

In This Article

Cost Containment and use of Other Testing

Management of syncope has become an unnecessarily expensive undertaking.[46] Nevertheless, recent data indicate that up to 42% of patients admitted with syncope are discharged without a diagnosis and 23% are re-admitted for recurrences, often followed by non-diagnostic evaluation.[10,11] The risk of adverse outcomes (e.g. mortality) is small but further expensive testing is not avoided. Many of these patients have undiagnosed VVS, which TT can provide preventing unnecessary and potentially harmful testing.

When the diagnosis is unclear from initial evaluation and there is no obvious cardiovascular cause for the episode, what is the next step? TT, when selected appropriately, following guidelines is cost-effective by avoiding use of more expensive and generally useless investigations, such as short-term ambulatory ECG monitoring (e.g. Holter monitoring), brain imaging, and EEG. European and North American guidelines are clear about this aspect of syncope investigation in recommending TT and advising against less effective, more expensive tests.[10,11] Guidelines also suggest[10,11,28] the use of TT as same-day assessment permitting diagnosis and preventing hospital admission.

Increasingly sophisticated, easy-to-place ILR/ICMs enhance diagnostic capacity but, even when chosen with care according to guideline recommendations,[10,11] they may still not offer a definitive mechanistic cause of syncope. ILR/ICMs are expensive and delay diagnosis by awaiting symptom recurrence. Furthermore, blood pressure is not recorded during episodes, which is pertinent to vasodepressor responses. TT offers blood pressure and ECG recording albeit in a laboratory-induced, rather than spontaneous episode.[10] However, ILR/ICMs are crucial for diagnosis when TT is negative or inconclusive, and patients suffer recurrences possibly with trauma. Thus, ILR/ICMs should be considered a necessary complement to holistic workup of unexplained syncope, not a TT competitor.