Tilt table test

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Tilt table test
Tilt table test showing POTS.webp
Results of a tilt table test in a person with POTS
MeSH D018667
A tilt table is used to bring a patient in a vegetative state to an upright position. (This video is meant to illustrate the table and its operation, not the test.)

A tilt table test (TTT), occasionally called upright tilt testing (UTT), is a medical procedure often used to diagnose dysautonomia or syncope. Patients with symptoms of dizziness or lightheadedness, with or without a loss of consciousness (fainting), suspected to be associated with a drop in blood pressure or positional tachycardia are good candidates for this test.

Contents

The procedure tests for causes of syncope by attempting to cause syncope by having the patient lie flat on a special table or bed and then be monitored with ECG and a blood pressure monitor that measure continuous, beat to beat, non-invasively. The table then creates a change in posture from lying to standing.

Indications

TTT may be indicated when the initial evaluation for syncope fails to provide a definitive, highly probable, or potential diagnosis, but instead raises clinical suspicion of reflex syncope, orthostatic hypotension, postural orthostatic tachycardia syndrome, or psychogenic pseudosyncope. TTT can help further investigate these conditions and aid in establishing an accurate diagnosis. [1]

Preparations

Before taking the test, the patient may be instructed to fast for a period before the test will take place and to stop taking any medications. On the day of the tilt table test, an intravenous line may be placed in case the patient needs to be given medications quickly; however, this may influence the results of the test and may only be indicated in particular circumstances. More recently, most investigators monitor cerebral perfusion pressure using mean flow velocity recording with transcranial Doppler ultrasound in supine horizontal position, during and after head-up tilt. An 18 MHz ultrasound transducer is placed on the temporal bone above the cheekbone, using headgear to hold the probe in place.[ citation needed ]

Procedure

A tilt table test can be done in different ways and be modified for individual circumstances. In some cases, the patient will be strapped to a tilt table lying flat and then tilted or suspended completely or almost completely upright (as if standing). Most of the time, the patient is suspended at an angle of 60 to 80 degrees. Sometimes, the patient will be given a drug, such as glyceryl trinitrate (nitroglycerin) or isoproterenol, to create further susceptibility to the test. [2] In all cases, the patient is instructed not to move. Symptoms, blood pressure, pulse, electrocardiogram, and sometimes blood oxygen saturation are recorded. The test either ends when the patient faints or develops other significant symptoms, or after a set period (usually from 20 to 45 minutes, depending on the facility or individualized protocol). [3]

Diagnostic symptoms

A tilt table test is considered positive if the patient experiences symptoms associated with a drop in blood pressure or cardiac arrhythmia. A normal person's blood pressure will not drop dramatically while standing, because the body will compensate for this posture with a slight increase in heart rate and constriction of the blood vessels in the legs. If this process does not function normally in the patient, the test could provoke signs and symptoms ranging from minor lightheadedness to a very severe cardiac episode, depending on the person.

A common side effect during tilt table testing is a feeling of heaviness and warmth in the lower extremities. This is due to blood pooling in the legs and, to onlookers, the patient's lower extremities may appear blotchy, pink, or red.

Dizziness or lightheadedness are also likely to occur in susceptible patients. Tilt table testing could provoke fainting or syncope. It is the purpose of the test to provoke these symptoms, in order to aid in diagnosis. [4] It may not be appropriate, or indeed even possible, to stop the test before fainting occurs, as the drop in blood pressure or pulse rate associated with fainting can come on in seconds. This is why the patient's blood pressure and ECG should be continuously monitored during the test. [5] If at any time in tilt table testing a patient loses consciousness, they will be returned to a supine or head down position and will be given immediate medical attention, which could include being given fluids or perhaps atropine or a sympathomimetic drug like epinephrine or ephedrine which will raise blood pressure and heart rate rapidly. In extreme cases, tilt table testing could provoke seizures or even cause the heart to stop. The heart resumes beating normally upon being returned to a flat or head-down position.

A drop in blood pressure during the tilt table test is indicative of orthostatic hypotension. A marked increase in heart rate in the absence of orthostatic hypotension is indicative of postural orthostatic tachycardia syndrome. [6]

See also

Related Research Articles

Orthostatic hypotension, also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when they are standing up (orthostasis) or sitting down. Primary orthostatic hypotension is also often referred to as neurogenic orthostatic hypotension. The drop in blood pressure may be sudden, within 3 minutes or gradual. It is defined as a fall in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg after 3 minutes of standing. It occurs predominantly by delayed constriction of the lower body blood vessels, which is normally required to maintain adequate blood pressure when changing the position to standing. As a result, blood pools in the blood vessels of the legs for a longer period, and less is returned to the heart, thereby leading to a reduced cardiac output and inadequate blood flow to the brain.

<span class="mw-page-title-main">Tachycardia</span> Heart rate exceeding normal resting rate

Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal or abnormal.

<span class="mw-page-title-main">Dysautonomia</span> Any disease or malfunction of the autonomic nervous system

Dysautonomia, autonomic failure, or autonomic dysfunction is a condition in which the autonomic nervous system (ANS) does not work properly. This may affect the functioning of the heart, bladder, intestines, sweat glands, pupils, and blood vessels. Dysautonomia has many causes, not all of which may be classified as neuropathic. A number of conditions can feature dysautonomia, such as Parkinson's disease, multiple system atrophy, dementia with Lewy bodies, Ehlers–Danlos syndromes, autoimmune autonomic ganglionopathy and autonomic neuropathy, HIV/AIDS, mitochondrial cytopathy, pure autonomic failure, autism, and postural orthostatic tachycardia syndrome.

<span class="mw-page-title-main">Sinus node dysfunction</span> Medical condition

Sinus node dysfunction (SND), also known as sick sinus syndrome (SSS), is a group of abnormal heart rhythms (arrhythmias) usually caused by a malfunction of the sinus node, the heart's primary pacemaker. Tachycardia-bradycardia syndrome is a variant of sick sinus syndrome in which the arrhythmia alternates between fast and slow heart rates.

<span class="mw-page-title-main">Palpitations</span> Perceived cardiac abnormality in which ones heartbeat can be felt

Palpitations are perceived abnormalities of the heartbeat characterized by awareness of cardiac muscle contractions in the chest, which is further characterized by the hard, fast and/or irregular beatings of the heart.

<span class="mw-page-title-main">Hypotension</span> Abnormally low blood pressure

Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is indicated by two numbers, the systolic blood pressure and the diastolic blood pressure, which are the maximum and minimum blood pressures within the cardiac cycle, respectively. A systolic blood pressure of less than 90 millimeters of mercury (mmHg) or diastolic of less than 60 mmHg is generally considered to be hypotension. Different numbers apply to children. However, in practice, blood pressure is considered too low only if noticeable symptoms are present.

<span class="mw-page-title-main">Dizziness</span> Neurological condition causing impairment in spatial perception and stability

Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness.

<span class="mw-page-title-main">Reflex syncope</span> Brief loss of consciousness due to a neurologically induced drop in blood pressure

Reflex syncope is a brief loss of consciousness due to a neurologically induced drop in blood pressure and/or a decrease in heart rate. Before an affected person passes out, there may be sweating, a decreased ability to see, or ringing in the ears. Occasionally, the person may twitch while unconscious. Complications of reflex syncope include injury due to a fall.

Orthostatic intolerance (OI) is the development of symptoms when standing upright that are relieved when reclining. There are many types of orthostatic intolerance. OI can be a subcategory of dysautonomia, a disorder of the autonomic nervous system occurring when an individual stands up. Some animal species with orthostatic hypotension have evolved to cope with orthostatic disturbances.

<span class="mw-page-title-main">Postural orthostatic tachycardia syndrome</span> Abnormally high heart rate after a postural change

Postural orthostatic tachycardia syndrome (POTS) is a condition characterized by an abnormally large increase in heart rate upon sitting up or standing. POTS is a disorder of the autonomic nervous system that can lead to a variety of symptoms, including lightheadedness, brain fog, blurred vision, weakness, fatigue, headaches, heart palpitations, exercise intolerance, nausea, diminished concentration, tremulousness (shaking), syncope (fainting), coldness or pain in the extremities, numbness or tingling in the extremities, chest pain, and shortness of breath. Other conditions associated with POTS include myalgic encephalomyelitis/chronic fatigue syndrome, migraine headaches, Ehlers–Danlos syndrome, asthma, autoimmune disease, vasovagal syncope, and mast cell activation syndrome. POTS symptoms may be treated with lifestyle changes such as increasing fluid, electrolyte, and salt intake, wearing compression stockings, gentle and slow postural changes, avoiding prolonged bedrest, medication, and physical therapy.

<span class="mw-page-title-main">Sinus tachycardia</span> Sinus rhythm with a rate that is higher than normal

Sinus tachycardia is a sinus rhythm of the heart, with an increased rate of electrical discharge from the sinoatrial node, resulting in a tachycardia, a heart rate that is higher than the upper limit of normal.

<span class="mw-page-title-main">Midodrine</span> Vasopressor/antihypotensive agent

Midodrine, sold under the brand names ProAmatine and Orvaten among others, is a vasopressor or antihypotensive medication used to treat orthostatic hypotension and urinary incontinence. It is taken by mouth.

Lightheadedness is a common and typically unpleasant sensation of dizziness or a feeling that one may faint. The sensation of lightheadedness can be short-lived, prolonged, or, rarely, recurring. In addition to dizziness, the individual may feel as though their head is weightless. The individual may also feel as though the room is "spinning" or moving (vertigo). Most causes of lightheadedness are not serious and either cure themselves quickly or are easily treated.

<span class="mw-page-title-main">Pure autonomic failure</span> Medical condition

Pure autonomic failure (PAF) is an uncommon, sporadic neurodegenerative condition marked by a steadily declining autonomic regulation. Bradbury and Eggleston originally described pure autonomic failure in 1925.

<span class="mw-page-title-main">Inappropriate sinus tachycardia</span> Syndrome where the sinus heart rate is inexplicably faster than expected

Inappropriate sinus tachycardia (IST) is defined as sinus tachycardia that is not caused by identifiable medical ailments, a physiological reaction, or pharmaceuticals (a diagnosis of exclusion) and is accompanied by symptoms, frequently invalidating and affecting quality of life. IST symptoms include palpitations, chest discomfort, exhaustion, shortness of breath, presyncope, and syncope.

<span class="mw-page-title-main">Syncope (medicine)</span> Transient loss of consciousness and postural tone

Syncope, commonly known as fainting or passing out, is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery. It is caused by a decrease in blood flow to the brain, typically from low blood pressure. There are sometimes symptoms before the loss of consciousness such as lightheadedness, sweating, pale skin, blurred vision, nausea, vomiting, or feeling warm. Syncope may also be associated with a short episode of muscle twitching. Psychiatric causes can also be determined when a patient experiences fear, anxiety, or panic; particularly before a stressful event, usually medical in nature. When consciousness and muscle strength are not completely lost, it is called presyncope. It is recommended that presyncope be treated the same as syncope.

<span class="mw-page-title-main">Orthostatic headache</span> Medical condition

Orthostatic headache is a medical condition in which a person develops a headache while vertical and the headache is relieved when horizontal. Previously it was often misdiagnosed as different primary headache disorders such as migraine or tension headaches. Increasing awareness of the symptom and its causes has prevented delayed or missed diagnosis.

<span class="mw-page-title-main">Pacemaker syndrome</span> Medical condition

Pacemaker syndrome is a condition that represents the clinical consequences of suboptimal atrioventricular (AV) synchrony or AV dyssynchrony, regardless of the pacing mode, after pacemaker implantation. It is an iatrogenic disease—an adverse effect resulting from medical treatment—that is often underdiagnosed. In general, the symptoms of the syndrome are a combination of decreased cardiac output, loss of atrial contribution to ventricular filling, loss of total peripheral resistance response, and nonphysiologic pressure waves.

Orthostatic syncope refers to syncope resulting from a postural decrease in blood pressure, termed orthostatic hypotension.

<span class="mw-page-title-main">Autoimmune autonomic ganglionopathy</span> Medical condition

Autoimmune autonomic ganglionopathy is a type of immune-mediated autonomic failure that is associated with antibodies against the ganglionic nicotinic acetylcholine receptor present in sympathetic, parasympathetic, and enteric ganglia. Typical symptoms include gastrointestinal dysmotility, orthostatic hypotension, and tonic pupils. Many cases have a sudden onset, but others worsen over time, resembling degenerative forms of autonomic dysfunction. For milder cases, supportive treatment is used to manage symptoms. Plasma exchange, intravenous immunoglobulin, corticosteroids, or immunosuppression have been used successfully to treat more severe cases.

References

  1. ↑ van Zanten S, Sutton R, Hamrefors V, Fedorowski A, de Lange FJ (March 2024). "Tilt table testing, methodology and practical insights for the clinic". Clin Physiol Funct Imaging. 44 (2): 119–130. doi:10.1111/cpf.12859. hdl: 10044/1/107291 . PMID   37839043.
  2. ↑ Goldman L (2011). Goldman's Cecil Medicine (24th ed.). Philadelphia: Elsevier Saunders. p.  343. ISBN   978-1437727883.
  3. ↑ Mustafa Ahmed, M.D. (13 February 2015). "Tilt Test – Tilt Table Test Explained!". Abel Healthcare. Retrieved 19 February 2015.
  4. ↑ Richard N. Fogoros, M.D. (17 December 2014). "Tilt Table Testing". About Health. Archived from the original on 14 August 2007. Retrieved 19 February 2015.
  5. ↑ "Tilt Table Testing". University of Michigan. 2006. Archived from the original on 15 June 2007. Retrieved 19 February 2015.
  6. ↑ Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, Cheshire WP, Chelimsky T, Cortelli P, Gibbons CH, Goldstein DS, Hainsworth R, Hilz MJ, Jacob G, Kaufmann H, Jordan J, Lipsitz LA, Levine BD, Low PA, Mathias C, Raj SR, Robertson D, Sandroni P, Schatz I, Schondorff R, Stewart JM, van Dijk JG (April 2011). "Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome". Clinical Autonomic Research. 21 (2): 69–72. doi:10.1007/s10286-011-0119-5. PMID   21431947. S2CID   11628648.
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