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Abolish the Tilt Table Test for the Workup of Syncope!

2020; Lippincott Williams & Wilkins; Volume: 141; Issue: 5 Linguagem: Inglês

10.1161/circulationaha.119.043259

1524-4539

Nitin Kulkarni, Purav Mody, Benjamin D. Levine,

Psychosomatic Disorders and Their Treatments

HomeCirculationVol. 141, No. 5Abolish the Tilt Table Test for the Workup of Syncope! Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBAbolish the Tilt Table Test for the Workup of Syncope! Nitin Kulkarni, MD, Purav Mody, MD and Benjamin D. Levine, MD Nitin KulkarniNitin Kulkarni Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (N.K., P.M., B.D.L.). Veterans Administration North Texas Health System, Dallas (N.K., P.M.). , Purav ModyPurav Mody Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (N.K., P.M., B.D.L.). Veterans Administration North Texas Health System, Dallas (N.K., P.M.). and Benjamin D. LevineBenjamin D. Levine Benjamin D. Levine, MD, Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, The University of Texas Southwestern Medical Center, 7232 Greenville Avenue, Suite 435, Dallas, TX 75231. Email E-mail Address: [email protected] Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (N.K., P.M., B.D.L.). Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (B.D.L.). Originally published3 Feb 2020https://doi.org/10.1161/CIRCULATIONAHA.119.043259Circulation. 2020;141:335–337Testing in medicine is done for a reason. A medical test should be performed to establish or reject a diagnosis, quantify disease severity, monitor disease progression, or identify a treatment that could not have been determined before the test. The ultimate outcome of a useful test and the consequent intervention should be either that it (1) reduces morbidity (improves quality of life) or (2) reduces mortality (increases the quantity of life). How well a test accomplishes these outcomes must come with an acceptable risk/benefit ratio. Even if a test (or intervention) does not cause harm itself, the consequences of making an incorrect diagnosis resulting in a wrong course of therapy may cause harm. It is within this context that we argue that tilt table testing (TTT) for the workup of syncope should be abolished. We submit that the TTT fails to establish an explicit cause of syncope, is plagued by false positives, and never plays a role in guiding treatment. Given these limitations, we believe that TTT should stop being administered for these purposes.Syncope is a condition with a high lifetime prevalence accounting for 1% to 3% of emergency room visits with a >30% rate of subsequent hospital admission.1 Much has been published regarding the cost of syncope to the health care system, and the subsequent high use rates of unnecessary testing, especially neurological imaging.2 The cornerstones in the initial evaluation of a patient presenting with syncope are the history, physical examination (including orthostatic vitals), and ECG. The diagnostic accuracy of using this clinical approach is 88%.3 Furthermore, neurally mediated syncope (NMS), also called vasovagal syncope, accounts for the majority of presentations. The patient's history is key to establishing the diagnosis of NMS. The presence of typical contextual triggers (pain, fear, emotional stress, phlebotomy/needle sticks, postexercise, heat, micturition, etc), a long history of syncopal events, the presence of prodromal symptoms (warmth or nausea), postsyncope fatigue, young age, and the absence of known heart disease are all suggestive of NMS.Given the benign prognosis of NMS and the high diagnostic accuracy of the history, examination, and ECG in making a diagnosis, what does TTT add? The latest iteration of the US syncope guidelines recommend TTT in patients with suspected NMS who have an unclear diagnosis after initial evaluation.2 However, syncope during TTT is notoriously nonspecific. The European syncope guidelines note that whereas 92% of patients with NMS will have a positive TTT, 47% of patients with arrhythmic syncope also will have a positive TTT.4 The use of pharmacological provocation (eg, sublingual nitroglycerin or isoproterenol) increases the risk of precipitating syncope during TTT, even in individuals who have never had a syncopal event. Although such events are often called false positives, we contend that it simply induces a highly conserved reflex (ie, a fall in cerebral perfusion pressure from a decrease in cardiac output; heart rate or stroke volume, peripheral resistance, or both) regardless of whether or not the patient has ever had syncope as previously described by us.5It is important to emphasize that virtually everyone will have syncope given an adequate hemodynamic stress to a circulatory condition that exaggerates central hypovolemia (G-load, heat, exercise, etc). Syncope during orthostatic stress may be especially common in athletes with large compliant hearts (and therefore a large fall in stroke volume during orthostasis) and large vasodilatory capacity, thus providing further evidence that TTT-provoked syncope does not equate to having a disease. Therefore, the provocation of syncope during TTT does not help the physician in elucidating the mechanism for the patient's syncopal events, as the mechanism of syncope during TTT and during the patient's clinical events may be entirely different.Indeed, given the primacy of symptoms for the diagnosis of NMS, it is difficult to imagine a scenario where the results of TTT will change a physician's pretest diagnosis. For example, if a patient has classic clinical features of NMS, a TTT that does not provoke syncope would not change that diagnosis. Conversely, for a patient with a concerning history of syncope, such as associated with palpitations or during exercise, or in a patient with a history of cardiovascular disease, the presence of NMS on TTT should never preclude a life-threatening pathophysiology; the case of former Boston Celtics basketball star Reggie Lewis serves as a stark reminder of this lesson. Although he had a concerning episode of syncope during a basketball game, a positive TTT led to the diagnosis of NMS. He subsequently died of cardiac arrest from ventricular fibrillation at the age of 27 years. Therefore, TTT at best adds little diagnostic value for determining the etiology of undiagnosed syncope, and at worst may lead to false reassurance in patients with malignant etiologies.In what setting could TTT be helpful? Both US and European guidelines note that TTT plays a role in patients with orthostatic hypotension and postural orthostatic tachycardia syndrome.2,4 However, a simple active stand test is more clinically relevant, reproduces the circumstances of the patient's complaint, and is just as sensitive but more specific than TTT for diagnosing these conditions. Moreover, an active stand test (5–10 min quiet standing) is simple and can be done cheaply in an office setting without specialized equipment. This test will also distinguish patients with early orthostatic hypotension versus delayed orthostatic hypotension (ie, blood pressure reduction >3 min after assuming the standing position). The active stand test should be done in all patients with suspected orthostatic hypotension or postural orthostatic tachycardia syndrome.Some clinicians have used TTT in patients with known NMS to assess the effectiveness of treatment such as physical countermaneuvers, pharmacological measures, or pacing. However, the US syncope guidelines give this strategy a class III recommendation because the reproducibility, prognostic implications, mechanism, and timing of NMS can be quite variable.2Finally, the outcomes of TTT do not lead to therapeutic interventions that reduce morbidity, recurrent events, or mortality. For example, TTT is purported to be useful in distinguishing between the cardioinhibitory and vasodepressor predominant forms of NMS. However, we believe that the utility of this capability is limited because the mechanism by which syncope occurs in a laboratory setting can be quite different from what happens in the field. For example, if a patient has a cardioinhibitory response on the tilt table (especially after pharmacologic provocation), but not in the field, then pacing will not likely prevent future syncope. Additionally, in the current era of sophisticated ambulatory ECG monitoring devices and implantable loop recorders, we believe TTT is unnecessary and indeed can be misleading in making this diagnosis. Remote ECG monitoring allows for correlation of arrhythmic events with clinical events, thus ensuring higher specificity and clearly linking the patients' symptoms with their rhythm. These techniques (longer than 24 hours) should be the cornerstone of diagnostic testing in patients for whom the diagnosis cannot be established with confidence on initial evaluation, or for whom confirmatory testing is necessary.In conclusion, the false positive rate in TTT is not trivial and can lead physicians and patients away from the true mechanism of syncope. We already have a problem with overuse of testing in the syncope patient. Let us stop contributing to this waste by abolishing the tilt table test for workup of syncope.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circBenjamin D. Levine, MD, Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, The University of Texas Southwestern Medical Center, 7232 Greenville Avenue, Suite 435, Dallas, TX 75231. Email [email protected]orgReferences1. Sun BC, Emond JA, Camargo CA. Characteristics and admission patterns of patients presenting with syncope to U.S. emergency departments, 1992-2000.Acad Emerg Med. 2004; 11:1029–1034. doi: 10.1197/j.aem.2004.05.032MedlineGoogle Scholar2. Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.Circulation. 2017; 136:e60–e122. doi: 10.1161/CIR.0000000000000499LinkGoogle Scholar3. van Dijk N, Boer KR, Colman N, Bakker A, Stam J, van Grieken JJ, Wilde AA, Linzer M, Reitsma JB, Wieling W. High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment study.J Cardiovasc Electrophysiol. 2008; 19:48–55. doi: 10.1111/j.1540-8167.2007.00984.xMedlineGoogle Scholar4. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, et al; ESC Scientific Document Group. 2018 ESC guidelines for the diagnosis and management of syncope.Eur Heart J. 2018; 39:1883–1948. doi: 10.1093/eurheartj/ehy037CrossrefMedlineGoogle Scholar5. Fu Q, Verheyden B, Wieling W, Levine BD. Cardiac output and sympathetic vasoconstrictor responses during upright tilt to presyncope in healthy humans.J Physiol. 2012; 590:1839–1848. doi: 10.1113/jphysiol.2011.224998CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Udyavar A and Deshpande S (2021) Evaluation and Management of Reflex Vasovagal Syncope—A Review, Indian Journal of Clinical Cardiology, 10.1177/26324636211050154, 3:1, (34-46), Online publication date: 1-Mar-2022. Patel M, Sampath S, Kapoor A, Damani D, Chellapuram N, Challa A, Kaur M, Walton R, Stavrakis S, Arunachalam S and Kulkarni K (2021) Advances in Cardiac Pacing: Arrhythmia Prediction, Prevention and Control Strategies, Frontiers in Physiology, 10.3389/fphys.2021.783241, 12 Wieling W and Jardine D (2021) Cardioneuroablation for recurrent vasovagal syncope: Important questions need to be answered, Heart Rhythm, 10.1016/j.hrthm.2021.08.032, 18:12, (2167-2168), Online publication date: 1-Dec-2021. van Dijk J, van Rossum I and Thijs R (2021) The pathophysiology of vasovagal syncope: Novel insights, Autonomic Neuroscience, 10.1016/j.autneu.2021.102899, 236, (102899), Online publication date: 1-Dec-2021. Thijs R, Brignole M, Falup-Pecurariu C, Fanciulli A, Freeman R, Guaraldi P, Jordan J, Habek M, Hilz M, Pavy-LeTraon A, Stankovic I, Struhal W, Sutton R, Wenning G and van Dijk J (2021) Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN), Autonomic Neuroscience, 10.1016/j.autneu.2021.102792, 233, (102792), Online publication date: 1-Jul-2021. Wieling W and Kaufmann H (2021) What is the best method to diagnose a vasovagal syncope?, Clinical Autonomic Research, 10.1007/s10286-021-00809-2, 31:3, (347-349), Online publication date: 1-Jun-2021. Thijs R, Brignole M, Falup-Pecurariu C, Fanciulli A, Freeman R, Guaraldi P, Jordan J, Habek M, Hilz M, Traon A, Stankovic I, Struhal W, Sutton R, Wenning G and Van Dijk J (2021) Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness, Clinical Autonomic Research, 10.1007/s10286-020-00738-6, 31:3, (369-384), Online publication date: 1-Jun-2021. Sutton R, Fedorowski A, Olshansky B, Gert van Dijk J, Abe H, Brignole M, de Lange F, Kenny R, Lim P, Moya A, Rosen S, Russo V, Stewart J, Thijs R and Benditt D (2021) Tilt testing remains a valuable asset, European Heart Journal, 10.1093/eurheartj/ehab084, 42:17, (1654-1660), Online publication date: 1-May-2021. Aksu T, Mandrola J and Raj S (2021) Permanent pacing for recurrent vasovagal syncope: New answers or just more questions?, Journal of Electrocardiology, 10.1016/j.jelectrocard.2021.01.010, 65, (88-90), Online publication date: 1-Mar-2021. Levine B and Mody P (2020) Response by Levine and Mody to Letter Regarding Article, "Abolish the Tilt Table Test for the Workup of Syncope!", Circulation, 141:25, (e946-e947), Online publication date: 23-Jun-2020.Sutton R, Fedorowski A and Benditt D (2020) Letter by Sutton et al Regarding Article, "Abolish the Tilt Table Test for the Workup of Syncope!", Circulation, 141:25, (e944-e945), Online publication date: 23-Jun-2020. Chrysant S (2020) The tilt table test is useful for the diagnosis of vasovagal syncope and should not be abolished, The Journal of Clinical Hypertension, 10.1111/jch.13846, 22:4, (686-689), Online publication date: 1-Apr-2020. February 4, 2020Vol 141, Issue 5 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.043259PMID: 32011926 Originally publishedFebruary 3, 2020 Keywordssyncopequality of lifedisease progressionPDF download Advertisement SubjectsDiagnostic Testing