Tilt Table Test: State of The Art

Barón-Esquivias, Gonzalo and Martínez-Rubio, Antoni (2003) Tilt Table Test: State of The Art. [Journal (Paginated)]

This is the latest version of this eprint.

Full text available as:



Vasovagal syncope is the most frequent form of syncope of unknown aetiology. Since 1986, the tilt-table test has become an important tool in the diagnosis of vasovagal syncope. Before this test was introduced, several patients were submitted to a multitude of tests although most of them did little more than waste of resources. The similarity between clinical and induced vasovagal syncope during the test shows its value. The tilt-table test yields a range of positive results from 60% to 70%, with a specificity greater than 85%. The results are also highly reproducible (data similar to provocation diagnostic tests such as the treadmill test) when drug-based protocols are used. This, with the absence of serious complications and very small number of side effects, makes probably the nitroglycerine protocol as the actually most recommended test for clinical practice.

Item Type:Journal (Paginated)
Keywords:vasovagal syncope, tilt-table test
Subjects:JOURNALS > Indian Pacing and Electrophysiology Journal
ID Code:4166
Deposited By:Indian Pacing and Electrophysiology, Journal
Deposited On:13 Apr 2005
Last Modified:11 Mar 2011 08:55

Available Versions of this Item

References in Article

Select the SEEK icon to attempt to find the referenced article. If it does not appear to be in cogprints you will be forwarded to the paracite service. Poorly formated references will probably not work.

1. Johnson RH, Spalding JMK. Disorders of the autonomic nervous system. Philadelphia: FA Davis, 1974: 269-279.

2. Foster M. A Text book of physiology. 5th ed. London: Macmillan; 1890.

3. Hill HB. The influence of the force of gravity on the circulation of the blood. J Physiol (Lond) 1895; 18: 15-53.

4. Gowers WR. A lecture on vagal and vasovagal attacks. Lancet 1907; 173: 716-724.

5. Cotton TF, Lewis T. Observations upon fainting attacks due to inhibitory cardiac impulses. Heart 1918-1920; 7: 23-34

6. Lewis T. Vasovagal syncope and the carotid sinus mechanism- with comments on Gower’s and Nothnagel’s syndrome. Br Med J, 1932; 1: 873-876.

7. Weissler AM, Warren JV, Estes EH, McIntosh HD, Leonard JJ. Vasodepressor syncope. Factors influencing cardiac output. Circulation 1957; XV: 875-882.

8. McMichael J, Sharpey Schafer EP. Cardiac output in man by a direct Fick method; effect of posture, venous pressure change, atropine and adrenaline. Br Heart J, 1944; 6: 33-40.

9. Davies R, Slater JDH, Forsling ML, Payne N. The response of arginine vasopressin and plasma rennin to postural change in normal man, with observations to syncope. Clin Sci, 1976; 51: 267-274.

10. Hellebrandt FA, Franseen EB. Physiologic study of vertical stance in man.

Physiol Rew, 1943; 23: 220-225.

11. Brigden W, Howarth S, Sharpey-Shaefer EP. Postural changes in the peripheral blood-flow of normal subjects with observations on vasovagal fainting reactions as a result of tilting, the lordotic posture, pregnancy and spinal anesthesia. Clin Sci Lond, 1950; 9: 79-90.

12. Stevens H, Fazekas J. Experimentally induced hypotension. Arch Neurol Psych, 1955; 73: 416-424.

13. Vogt FB. Tilt table and volume changes with short term deconditioning experiments. Aerospace Med, 1967; 38: 564-568.

14. Shvarts E. Reliability of quantifiable tilt table data. Aerospace Med, 1968; 39: 1094-1096.

15. Shvarts E, Meyerstein N. Tilt tolerance of young men and women Aerospace Med, 1970; 41: 253-255.

16. Kenny RA, Ingram A, Bayliss J, Sutton R. Head-up tilt: A useful test for investigating unexplained syncope. Lancet, 1986; 1: 1352-1355. Medline

17. Benditt DG, Ferguson DW, Grubb BP, Kapoor WN, Kugler J, Lerman BB, Maloney JD, Raviele A, Ross B, Sutton R, Wolk MJ, Wood DL. Tilt table Testing for assessing syncope. American College of cardiology. J Am Coll Cardiol, 1996; 28: 263-275. Medline

18. Benditt DG. Neurally mediated syncopal syndromes: Pathophysiological concepts and clinical evaluation. PACE, 1997; 20: 572-584. Medline

19. Grubb BP, Kosinski D. Tilt table testing. Concepts and limitations. PACE, 1997; 20(Pt II); 781-787. Medline

20. Sprangers RLH, Veerman DP, Karemarker JM, Wieling W. Initial circulatory responses to change in posture: Influence of the angle and speed of tilt. Clin Physiol, 1991; 11: 211-220. Medline

21. Chen MY, Goldenberg IF, Milstein S. Cardiac electrophysiologic and hemodynamic correlates of neurally mediated syncope. Am J Cardiol, 1989; 63: 66-72. Medline

22. Morillo CA, Klein GJ, Jones DL, Yee R. Time and frequency domain analices of Herat rate variability during orthostatic stress in patients with neurally mediated syncope. Am J Cardiol, 1994; 74: 1258-1262. Medline

23. Lippman N, Stein KM, Lerman BB. Failure to decrease parasympathetic tone during upright tilt predicts a positive tilt-table test. Am J Cardiol, 1995; 75: 591-595. Medline

24. Jardine DL, Melton IC, Crozier IG, English S, Bennet SI, Frampton CM, Ikram H. Decrease in cardiac output and muscle sympathetic activity during vasovagal syncope. Am J Physiol Heart Circ Physiol, 2002; 282: H1804-H1809. Medline

25. Benditt DG, Chen MY, Hansen R, Buetikofer J, Lurie K. Characterization of subcutaneous microvascular blood flow during tilt table-induced neurally mediated syncope. J Am Coll Cardiol, 1995; 25: 70-75. Medline

26. Chosy JJ, Graham DT. Catecholamines in vasovagal fainting. J Psychosom Res, 1965; 9: 189-194. Medline

27. Sander-Jensen K, Secher NH, Astrup A et al. Hypotension induced by passive head-up tilt : endocrine and circulatory mechanism. Am J Physiol, 1986; 251: R742-R748. Medline

28. Alboni P, Dinelli M, Grupillo P, Bondanelli M, Bettiol K, Marchi P, Uberti EC. Haemodynamics changes early in prodromal symptoms of vasovagal syncope. Europace, 2002; 4: 333-338. Medline

29. Smith GDP, Watson LP, Mathias CJ. Cardiovascular and cathecolamine changes induced by supine exercise and upright posture in vasovagal syncope. Comparisons with normal subjects and subjects with sympathetic denervation. Eur Heart J, 1996; 17: 1882-1890. Medline

30. Fitzpatrick A, Williams T, Ahmed R et al. Echocardiographic and endocrine changes during vasovagal syncope induced by prolonged head-up tilt. Eur J Cardiac Pacing Electrophysiol, 1992; 2: 121-128.

31. Sra JS, Murthy V, Natale A, Jazayeri MRDhala A, Deshpande S, Sheth M, Akhtar M. Circulatory and cathecolamine changes during head-up tilt testing in neurocardiogenic (vasovagal) syncope, Am J Cardiol, 1994; 73: 33-37. Medline

32. Pérez-Paredes M, Picó-Aracil F, Fuentes T, Sánchez JG, Expósito E, Gonzalvez M, González E, Nicolas F, Nuno JA, Ruiz-Ros JA, Ruipérez JA. Role of endogenous opiods in syncope induced by head-up tilt test and its relationship with isoproterenol-dependent and isoproterenol-independentneurally-mediated syncope. Int J Cardiol, 1998; 67: 211-218. Medline

33. Task Force Report. Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J, 2001; 22: 1256-1306. Medline

34. Fitzpatrick AP, Theodorakis G, Vardas P, Sutton R. Methodology of head-up tilt testing in patients with unexplained syncope. J Am Coll Cardiol, 1991;17: 125-130.

35. Stein KM, Slotwiner DJ, Mittal S, Scheiner M, Markowitz SM, Lerman BB. Formal analysis of the optimal duration of tilt testing for the diagnosis of neurally mediated syncope. Am Heart J, 2001; 141: 282-288.

36. Barón-Esquivias G, Pedrote A, Cayuela A, Valle JI, Fernández JM, Estepa MJ, Martínez-Morentín E, Navarro M, Burgos J. Age and gender differences in basal and isoprenaline protocols for head-up tilt table testing. Europace, 2001; 3(2): 136-140.

37. Almquist A, Goldberg IF, Milstein S, Chen MY, Chen XC, Hansen R. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med, 1989;320:346-351.

38. Kapoor WN, Brant N. Evaluation of syncope by upright tilt testing with isoproterenol. A non-specific test. Ann Intern Med, 1992; 116: 358-363.

39. Morillo CA, Klein GJ, Zandri S, Yee R. Diagnostic accuracy of a low-dose isoproterenol head-up tilt protocol. Am Heart J, 1995; 129:901-906.

40. Carlioz R, Graux P, Haye J, Letourneau T, Guyomar Y, Hubert E, et al. Prospective evaluation of high-dose or low-dose isoproterenol upright tilt protocol for unexplained syncope in young adults. Am Heart J, 1997; 133: 346-352.

41. Shen WK, Jahangir A, Beinborn D, Lohse CM, Hodge DO, Rea R, et al. Utility of a single-stage isoproterenol tilt table test in adults. J Am Coll Cardiol, 1999; 33: 985-990.

42. Kawai N, Sotobata I, Noda S, Okada M, Kondo T, Yokota M, Yamauchi K, Tsuzuki J. Correlation between the direction of the interventricular septum estimated with transmission computed tomography and the initial QRS vectors. J Electrocardiol 1984;17:401-8

43. Theodorakis GN, Markianos M, zarvalis E, Livanis EG, Flevari P, Kremastinos DT. Provocation of neurocardiogenic syncope by clomipramine administration during the head-up tilt test in vasovagal syncope. J Am Coll Cardiol, 2000; 36: 174-178.

44. Theodorakis GN, Livanis EG, Leftheriotis D, Flevari P, Markianos M, Kremastinos DT. Head-up tilt test with clomipramine challenge in vasovagal syndrome-a new tilt testing protocol. Eur Heart J, 2003;24(7):658-663.

45. Raviele A, Gasparini G, Di Pede F, Menozzi C, Brignole M, Dinelli M, Alboni P, Piccolo E. Nitroglycerin infusión during upright tilt: A new test for the diagnosis of vasovagal syncope. Am Heart J, 1994; 127:103-111.

46. Raviele A, Menozzi C, Brignole M, Gasparini G, Alboni P, Musso G, Lolli G, Oddone D, Dinelli M, Mureddu R. Value of head-up tilt testing potentiated with sublingual nitroglycerin to assess the origin of unexplained syncope. Am J Cardiol, 1995; 76: 267-272.

47. Aerts A, Dendale P, Strobel G, Block P. Sublingual nitrates during head-up tilt testing for the diagnosis of vasovagal syncope. Am Heart J, 1997; 133: 504-507.

48. Natale A, Sra J, Akhtar M, Kusmirek L, Tomassoni G, Leonelli F, Newby K, Beheiry S, Pacifico A. Use of sublingual nitroglycerin during head-up tilt-table testing in patients > 60 years of age. Am J Cardiol, 1998; 82: 1210-1213.

49. Del Rosso A, Bartoli P, Bartoletti A, Brandinelli A, Bonechi F, Maioli M, Mazza F et al. Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope. Am Heart J, 1998; 135: 564-570.

50. Foglia-Monzillo G, Giada F, Beretta S, Corrado G, Santarone M, Rábiele A. Reproducibility of head-up tilt testing potentiated with sublingual nitroglycerin in patients with syncope. Am J Cardiol, 1999; 84: 284-288.

51. Bartoletti A, Gaggioli G, Menozzi C, Bottoni N, Del Rosso A, Mureddu R, Musso G, , Foglia Manzillo G, Bonfigli B, Brignole M. Head-up tilt testing potentiated with oral nitroglycerin. A randomized trial of the contribution of a drug-free phase and a nitroglycerin phase in the diagnosis of neurally mediated syncope. Europace, 1999; 1: 183-186.

52. Bartoletti A, Alboni P, Ammirati F, Brignole M, Del Rosso A, Foglia Manzillo G, Menozzi C, Raviele A, Sutton R. “The Italian protocol”: a simplified head-up tilt testing potentiated with oral nitroglycerin to asses patients with unexplained syncope. Europace, 2000; 2 (4): 339-342.

53. Pérez-Paredes M, Barón-Esquivias G, Ruiz Ros JA, Pedrote A, Jiménez DM, Valle JI, Carnero A, Gonzálvez M. Results of shortened head-up tilt testing potenciated with sublingual nitroglicerin in a large cohort of patients with unexplained syncope”. Eur Heart J, 2002; 23 (abst suppl): 286.

54. Raviele A, Giada F, Brignole M, Mennozi C, Marangoni E, Foglia-Manzillo G, Alboni P. Comparison of diagnostic accuracy of sublingual nitroglycerin test and low-dose isoproterenol test in patients with unexplained syncope. Am J Cardiol, 2000; 85: 1194-1198.

55. Graham LA, Gray JC, Kenny RA. Comparison of provocative tets for unexplained syncope. Isoprenaline and glyceryl trinitrate for diagnosing syncope. Eur Heart J, 2001; 22: 497-503.

56. McIntosh SJ, Lawson J, Kenny RA. Intravenous cannulation alters the specificity of head-up tilt test for vasovagal syncope in elderly patients. Age Ageing, 1994; 23: 317-319.

57. Barón-Esquivias G, Pedrote A, Cayuela A, Valle JI, Fernández JM, Arana E, et al. Long-term outcome of patients with asystole induced by head-up tilt test. Eur Heart J, 2002; 23: 483-489.

58. Grubb BP, Kosinski D. Neurocardiogenic syncope and related syndromes of orthostatic intolerance. Cardiology Review, 1997; 5(4): 182-189.

59. Sutton R, Petersen M, Brignole M, Raviele A, Menozzi C, Giani P. Proposed classification for tilt induced vasovagal syncope. Eur J Cardiac Pacing Electrophysiol, 1992; 3: 180-183.

60. Brignole M, Menozzi C, Del Rosso A, Costa G, Gaggioli G, Bottoni N, Bartoli P, Sutton R. New classification of haemodynamics of vasovagal syncope: Beyond the VASIS classification; analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Europace, 2000; 2: 66-76.

61. Moya A, Permanyer-Miralda G Sagrista-Sauleda J, Carne X, Rius T, Mont L, Soler-Soler J. Limitations of head up tilt test for evaluating the efficacy of therapeutic interventions in patients with vasovagal syncope: Results of a controlled study of etilefrine versus placebo. J Am Coll Cardiol, 1995; 25: 65-69.

62. Morillo C, Klein GJ, Gersh BJ. Can Serial tilt testing be used to evaluate therapy in neurally mediated syncope? Am J Cardiol, 1996; 77: 521-523.

63. Sagrista-Sauleda J, Romero B, Permanyer-Miranda G, Moya A, Soler-Soler J. Reproductibility of sequential head-up tilt testing in patients with recent syncope, normal ECG and no structural Herat disease. Eur Heart J, 2002; 23: 1706-1713.

64. Di-Girolamo E, Di-Torio C, Leonzio L, et al. Usefulness of a tilt training program for the prevention of refractory neurocardiogenic syncope in adolescents: a controlled study. Circulation, 1999; 100: 1798-1801. Medline

Free Full Text

65. Reybrouck T, Heidbuchel H, Van de Werf F, Ector H. Tilt Training: a treatment for malignant and recurrent neurocardiogenic syncope. Pacing Clin Electrophysiol, 2000; 23: 493-498.

66. Pedrote A, Errazquin J, Quero J, Sobrino M, Hernández MC. Prolonged cardiac asystole that requires resuscitation maneuvers during a Head-up tilt table test. Rev Esp Cardiol, 1993; 46: 313-315.

67. Vlay SC, Brodsky C, Vlay L. Safety and tolerability of an aggressive tilt table test protocol in the evaluation of patients with suspected neurocardiogenic syncope. PACE, 2000; 23 : 441-445.

68. Wang CH, Lee CC, Cherng WJ. Coronary vasospasm induced during isoproterenol head-up tilt test. Am J Cardiol, 1997; 80; 1508-1510.


Repository Staff Only: item control page