Head-up Tilt Test In Patients Research Articles

Gender related differences in active renin, aldosterone and big endothelin concentration during head-up tilt testing in patients with isolated vasovagal syncope

Introduction and objectiveNeuroendocrine dysregulation seems to play the main role in liberation of abnormal vasovagal reflex, and the pathomechanism can be gender-related. The aim of the study was to assess changes in concentration of active renin (R), aldosterone (A) and big endothelin (BE) at rest and tilting in patients with vasovagal syncope in reference to gender and result of the head-up tilt test (HUTT).Material and methodsStudy involved 133 patients with syncope. In all HUTT were performed. Concentrations of the analyzed hormones were measured at the last minute of the rest, at the 10th minute of tilting and at the end of the test. An aldosterone/renin ratio (A/R) was calculated for each of the phases.ResultsHUTT(+) was observed in 87subjects (65%). During tilting a gradual increase of R and A was observed. The highest A/R was present in women HUTT(-) (p=0.040), contrary to non-fainting men in which decrease of A/R was accompanied with the highest absolute values at the end of the test (>18.6 pg/ml and A/R ratio at the end of the test <2.53 revealed to be independent predictors of syncope during tilt. The increase of R concentration during tilting <1.26 fold and the lack of increase of A predicted syncope during passive phase. In men, A concentration at the end of the test <44.0 pg/ml and the increase of A during tilting less than 2.10 fold, independently predicted positive result. None of analyzed parameters was pointed as an independent factor of syncope during passive phase. In women, R concentration at 10th minute of tilting >18.6 pg/ml and A/R ratio at the end of the test <2.53 revealed to be independent predictors of syncope during tilt. The increase of R concentration during tilting <1.26 fold and the lack of increase of A predicted syncope during passive phase. In men, A concentration at the end of the test <44.0 pg/ml and the increase of A during tilting less than 2.10 fold, independently predicted positive result. None of analyzed parameters was pointed as an independent factor of syncope during passive phase.ConclusionsThe activity of the vasoactive hormones is different in women and men and can determine the result of the test and the tolerance to passive tilting.

Clinical Features of Patients Undergoing the Head-Up Tilt Test and Its Safety and Efficacy in Diagnosing Vasovagal Syncope in 4,873 Patients.

Background: The head-up tilt test (HUTT) is a useful diagnostic tool in patients with suspected vasovagal syncope (VVS).Objectives: We aimed to investigate the direct drug-potentiated HUTT in patients with recurrent syncope or precursor syncope and to assess the diagnostic value of the direct drug-potentiated HUTT.Methods: The medical history and direct drug-potentiated HUTT records of patients who complained of syncope or precursor syncope and who visited The Xianyang Central Hospital from January 2016 to December 2020 were retrospectively reviewed.Results: A total of 4,873 patients (age = 43.8 ± 17.6 years; male = 2,064 [42.4%]) were enrolled in our study. Overall, 2,343 (48.1%) showed positive responses as follows: 1,260 (25.9%) with the mixed type, 34 (0.7%) with the cardioinhibitory type, 580 (11.9%) with the vasodepressor type, 179 (3.7%) with postural tachycardia syndrome (POTS), and 290 (6.0%) with orthostatic hypotension (OH). The study showed that prior to syncope or near-syncope symptoms, patients first presented an increase in heart rate (HR), followed by decreases in blood pressure (BP) and HR successively. Among the patients in the syncope group, the sensitivity of the HUTT was 65.9%, which was significantly higher than a sensitivity of 44.8% for patients in the non-syncope group (P < 0.01). The sensitivity of the HUTT was higher for females than males in both the syncope group (52.6% in males and 77.9% in females, P < 0.01) and the non-syncope group (36.5% in males and 50.6% in females, P < 0.01). Within the four age groups (<20, 21–40, 41–60, and >60 years old), the sensitivities were 74.7%, 67.7%, 45.6%, and 31.2%, respectively. And all gender, age and symptom (whether suffered from a syncope or not) significantly affected the positive responses of HUTT. There were two adverse events and no deaths during the HUTT in this study.Conclusion: The direct drug-potentiated HUTT is a safe and highly sensitive tool with which to diagnose VVS. Patients with precursor syncope symptoms without syncope should undergo a HUTT, especially young females presenting with weakness and sweating, which can decrease the probability of a misdiagnosis or a missed diagnosis.

Head-up tilt test diagnostic yield in syncope diagnosis

BackgroundThe European Syncope Guidelines (ESG) recommend the use of Head-up tilt test (HUT) in case of suspicion of vasovagal syncope (VVS) or orthostatic hypotensive syncope (OHS) after an adequate initial inconclusive evaluation. We report a single center experience in the scenario of suspected VVS or OHS, who underwent HUT in patients referred to a Syncope Clinic after ruling out high-risk causes. MethodsWe prospectively and consecutively included all syncopal patients that were referred for HUT, by their attending physician after performing a series of diagnostic tests to rule out cardiac etiology. The clinical history and diagnostic tests performed were reviewed prior to HUT. Patients were pre-classified according to the recommendations from the ESG as; VVS, OHS or Syncope of Unknown Etiology (SUE). ResultsWe studied 1058 patients, 558 (52.7%) males, mean age 46.5 ± 20.1 yr. There were no gender differences in age, risk factors, previous heart diseases, ECG findings or number of previous tests. Based on the ESG criteria a significant number of diagnostic tests were probably unnecessarily performed. HUT was positive in 609 patients (57.5%). The rate of positive HUT according to pre-classification was significantly different among groups: 60% VVS, 46.1% OHS and 54.3% SUE (p = 0.037). Combining ESG recommendations and HUT results of the 1058 resulted in 762 (72%) diagnosed as VVS, 89 (8.4%) as OHS and 207 (19.5%) as SUE. ConclusionsAppropriate application of ESG recommendations combined with HUT, identified 81% of patients with non-cardiogenic syncope, potentially avoiding a significant number of unnecessary diagnostic tests.

Comparison of trinitroglycerin and adenosine as provocative agents for head-up tilt test in patients with unexplained syncope: a semi-crossover randomized clinical trial with prospective follow-up.

Head-up tilt test (HUTT) is a reasonable diagnostic evaluation for patients with suspected vasovagal syncope; however, its lengthy duration is a remarkable limitation. Although adenosine (AD), as an alternative provocative agent, is a promising option for tackling this shortcoming, it received little appreciation in the literature. We aimed to compare the efficacy and the time to elicit a positive response to HUTT for sublingual trinitroglycerin (TNG) and intravenous AD. Furthermore, we evaluated patients' outcomes in the follow-up. Patients with a chief complaint of transient loss of consciousness (TLOC) were evaluated. We randomized patients with the diagnosis of unexplained syncope after diagnostic evaluations, to undergo TNG-augmented HUTT or AD-augmented HUTT. They were crossed over to receive the other medication in case of negative response to the test. In the follow-up, we evaluated traumatic and non-traumatic TLOCs, hospitalization due to syncope, and death in patients. We randomized 132 patients (41.70 ± 19.37 years, 52.3% female) to receive TNG (n = 66) or AD (n = 66). Respectively, the positivity rate of TNG and AD for the first and the crossover-HUTT was 31.1% and 26.7%, and 20.5% and 26.2% with no statistically significant differences in both tests (P ˃ 0.50). The time to positive response was significantly shorter for AD than TNG (P < 0.001). In the follow-up, re-admission was significantly more prevalent in HUTT-negative patients compared to HUTT-positive patients (P = 0.04). We found that diagnostic yield of TNG and AD in HUTT is comparable, while AD acts 4 times faster than TNG in evoking a vasovagal response.

Serum Asymmetric Dimethylarginine Levels in Patients with Vasovagal Syncope.

Background and Objectives: Vasovagal syncope (VVS) is the most common cause of syncope and has multiple pathophysiological mechanisms. Asymmetric dimethylarginine (ADMA) is the major inhibitor of nitric oxide (NO). In this study, we aimed to investigate the relationship between plasma ADMA levels and syncope during the head-up tilt (HUT) test. Materials and Methods: Overall, 97 patients were included in this study. They were above 18 years of age and were admitted to our clinic with the complaint of at least one episode of syncope consistent with VVS. The HUT test was performed in all patients. Patients were divided into the following two groups based on the HUT test results: group 1 included 57 patients with a positive HUT test and group 2 included 35 patients with a negative HUT test. Blood samples were taken before and immediately after the HUT test to measure ADMA levels. Results: No significant intergroup differences were observed concerning gender and age (female gender 68% vs 60%; mean age 24.85 ± 4.01 vs 25.62 ± 3.54 years, respectively, for groups 1 and 2). ADMA values were similar between groups 1 and 2 before the HUT test [ADMA of 958 (544–1418) vs 951 (519–1269); p = 0.794]. In the negative HUT group, no significant differences were observed in ADMA levels before and after the HUT test [ADMA of 951 (519–1269) vs 951 (519–1566); p = 0.764]. However, in the positive HUT group, ADMA levels were significantly decreased following the HUT test [pretest ADMA of 958 (544–1418) vs post-test ADMA of 115 (67–198); p < 0.001]. Conclusion: ADMA levels significantly decreased after the HUT test in patients with VVS.

P2543QTc interval during head-up tilt testing in patients with neurocardiogenic syncope versus patients with orthostatic hypotensio

Abstract Background The QT interval reflects shifting from parasympathetic to sympathetic activity. During head-up tilt testing (HUTT) normal subjects show a QTc shortening, but during an abnormal response: 1) neurocardiogenic syncope or 2) orthostatic hypotension an altered balance between the parasympathetic to sympathetic is present and probably detected through changes in the QTc interval. Objective Compare dynamic changes of the QT, QTc intervals during head-up tilt test (HUTT) in patients with neurocardiogenic syncope (NCS) and with orthostatic hypotension due to autonomic failure (OH) Methods We studied 78 patients. 45 (51%) were female. All were symptomatic and had an abnormal HUTT according to each definition. We divided the population into two groups depending on the response, 1) NCS n=61 2) OH n=17. In all patients; heart rate, QT and QTc, were measured on a continuous 12-lead electrocardiogram Results NCS patients were significantly younger with female prevalence. The max HR and the SD of the HR were significantly higher. The QTc interval during positive HUTT was very different. In the NCS the QTc shortened from 407±25 to 367±49 (p=0.001) and in OH group the QTc prolonged from baseline 427±37 ms to HUTT 442±52 ms; p=0.001). Conclusion HUTT revealed significant QTc differences in patients with OH and NCS. Patients with a NCS the QTc interval shortened; but in those with OH the QTc significantly prolonged. This finding is in accordance with the autonomic imbalance and could explain the increase in sudden death observed in the OH population.

Analysis of Heart Rate Variability During Head-Up Tilt-Test in Patients with Vasovagal Syncope

Analysis of Heart Rate Variability During Head-Up Tilt-Test in Patients with Vasovagal Syncope

Nörojenik Senkop Geçiren Hastalarda Sağ Ventrikül Kontraksiyonunun Rolü

Introduction: Left ventricular hyper contractility has been thought to have a major role at early phases of vasovagal syncope. However the right ventricular function during syncope has not been delineated clearly. The present study evaluated the right myocardial contractility in patients who experienced vasovagal syncope during head-up tilt test (HUTT). Patients and Methods: A total of 89 Patients, who experienced syncope between January 2012 and March 2014, were included in the study. All the patients underwent HUTT and were followed by transthoracic echocardiography. Results: Fifty patients experienced syncope during HUTT. There was no significant difference between the patients, who experienced syncope versus who did not, in terms of gender, age, ejection fraction (p> 0.05). Mitral lateral annular systolic (s') velocity (14 ± 3.8 vs. 13.3 ± 3.6; p= 0.625), septal annular s' velocity (11 ± 3.7 vs. 10.3 ± 2; p= 0.951) were similar following HUTT in patients with and without syncope respectively. However, tricuspid valve lateral annular s' velocity after tilt testing was higher in patients, who experienced syncope (17 ± 2.7 vs. 15.1 ± 3.0; p= 0.003). Conclusion: While left ventricular functions are not affected, right ventricular contraction is more powerful in patients who experience syncope during HUTT.

P6627Assessment of tromboxan B2 serum concentration changes during head-up tilt test in patients with vasovagal syncope

P6627Assessment of tromboxan B2 serum concentration changes during head-up tilt test in patients with vasovagal syncope

P4426Evaluation of serum level changes of syndecan-1 in response to orthostatic stress during head-up tilt test in patients with vasovagal syncope

P4426Evaluation of serum level changes of syndecan-1 in response to orthostatic stress during head-up tilt test in patients with vasovagal syncope

Procoagulatory changes induced by head-up tilt test in patients with syncope: observational study

BackgroundOrthostatic hypercoagulability is proposed as a mechanism promoting cardiovascular and thromboembolic events after awakening and during prolonged orthostasis.We evaluated early changes in coagulation biomarkers induced by tilt testing among patients investigated for suspected syncope, aiming to test the hypothesis that orthostatic challenge evokes procoagulatory changes to a different degree according to diagnosis.MethodsOne-hundred-and-seventy-eight consecutive patients (age, 51 ± 21 years; 46% men) were analysed. Blood samples were collected during supine rest and after 3 min of 70° head-up tilt test (HUT) for determination of fibrinogen, von Willebrand factor antigen (VWF:Ag) and activity (VWF:GP1bA), factor VIII (FVIII:C), lupus anticoagulant (LA1), functional APC-resistance, and activated prothrombin time (APTT) with and without activated protein C (C+/−). Analyses were stratified according to age, sex and diagnosis.ResultsAfter 3 min in the upright position, VWF:Ag (1.28 ± 0.55 vs. 1.22 ± 0.54; p < 0.001) and fibrinogen (2.84 ± 0.60 vs. 2.75 ± 0.60, p < 0.001) increased, whereas APTT/C+/− (75.1 ± 18.8 vs. 84.3 ± 19.6 s; p < 0.001, and 30.8 ± 3.7 vs. 32.1 ± 3.8 s; p < 0.001, respectively) and APC-resistance (2.42 ± 0.43 vs. 2.60 ± 0.41, p < 0.001) decreased compared with supine values. Significant changes in fibrinogen were restricted to women (p < 0.001) who also had lower LA1 during HUT (p = 0.007), indicating increased coagulability. Diagnosis vasovagal syncope was associated with less increase in VWF:Ag during HUT compared to other diagnoses (0.01 ± 0.16 vs. 0.09 ± 0.17; p = 0.004).ConclusionsProcoagulatory changes in haemostatic plasma components are observed early during orthostasis in patients with history of syncope, irrespective of syncope aetiology. These findings may contribute to the understanding of orthostatic hypercoagulability and chronobiology of cardiovascular disease.

P472Heart rate variability during Westminster protocol of head-up tilt test in patients with neurocardiogenic syncope and healthy volunteers

P472Heart rate variability during Westminster protocol of head-up tilt test in patients with neurocardiogenic syncope and healthy volunteers

Association of leptin with orthostatic blood pressure changes in Parkinson's disease.

Leptin is involved in the regulation of blood pressure; however, no studies have evaluated the role of leptin in blood pressure changes during orthostatic stress in PD patients. The aim of this study was to determine whether plasma leptin levels influence orthostatic blood pressure changes in PD patients. We enrolled 55 patients and 25 age-matched healthy controls in this study. Associations between head-up tilt test measurements and leptin levels were evaluated. Systolic blood pressure changes during the head-up tilt tests were strongly correlated with leptin levels at baseline and at a 60-degree head-up tilt in PD patients, but not in control subjects. Multiple regression analysis also demonstrated that leptin levels were associated with orthostatic blood pressure changes. These observations suggest that low leptin levels may be associated with orthostatic hypotension during the head-up tilt test in patients with PD. © 2016 International Parkinson and Movement Disorder Society.

PT200 Time-Course of TromboxanB2 Serum Concentration During Head-Up Tilt Test in Patients With Vasovagal Syncope

PT200 Time-Course of TromboxanB2 Serum Concentration During Head-Up Tilt Test in Patients With Vasovagal Syncope

PM195 Flutuation of Nitric Oxide Serum Concentration During Head-Up Tilt Test in Patients With Vasovagal Syncope

PM195 Flutuation of Nitric Oxide Serum Concentration During Head-Up Tilt Test in Patients With Vasovagal Syncope

PM193 Possible Relation Between Syncope-Induced Rise of Brain Injury Markers and Clotting Disturbances During Positive Head-Up Tilt Test in Patients With Vasovagal Syndrome

PM193 Possible Relation Between Syncope-Induced Rise of Brain Injury Markers and Clotting Disturbances During Positive Head-Up Tilt Test in Patients With Vasovagal Syndrome

Detailed Relationship Between the Pattern of Blood Pressure Change During the Valsalva Maneuver and the Degree of Orthostatic Hypotension During the Head-Up Tilt Test in Patients With Orthostatic Intolerance: A Retrospective Case-Control Study.

Although the head-up tilt (HUT) test and Valsalva maneuver (VM) have been widely used to identify sympathetic adrenergic impairment, the detailed relationship between the degree of orthostatic hypotension (OH) during the HUT test and the pattern of blood pressure (BP) change during the VM remains unknown. This study was performed to investigate the relationship between the degree of OH during the HUT test and the pattern of BP change during the VM. During a 4-year period, a total of 132 consecutive patients with neurogenic OH and 60 healthy controls were enrolled. The degree of OH was defined as mild (associated with a fall in systolic BP [SBP] ≥ 20 < 30 on tilting, n = 49), moderate (associated with a fall in SBP ≥ 30 < 40 on tilting, n = 43), and severe (associated with a fall in SBP ≥ 40 on tilting, n = 40). A standardized battery of autonomic tests, including the HUT test and VM using Finometer devices for recording beat-to-beat BP and heart rate response, and a quantitative sudomotor axon reflex test, was performed. Sympathetic indexes (SIs 1–6) were calculated from the VM. A composite autonomic severity score (CASS) was also obtained to evaluate the severity and distribution of autonomic dysfunction. The degree of OH was compared with the BP decline and recovery during the VM. All indexes exhibited overall significant differences among tested groups (P < 0.001). Only SI 3 differentiated all subject groups. Compared with other SIs, SI 3 was best correlated with the amount of decrease in the mean SBP (R2 = 0.473, P < 0.001) on tilting. The decrease in mean SBP on tilting was best correlated with CASS adrenergic subscore. SI 3 can differentiate between groups with different degrees of OH. The SI 3 obtained during VM can improve the diagnostic accuracy of autonomic dysfunction in patients with different degree of OH.

Diagnostic role of head-up tilt test in patients with cough syncope.

The aim of this study was to describe the head-up tilt (HUT) test and carotid sinus massage (CSM) responses, and the occurrence of syncope with coughing during HUT in a large cohort of patients. A total of 5133 HUT were retrospectively analysed to identify patients with cough syncope. Head-up tilt followed by CSM were performed. Patients were made to cough on two separate occasions in an attempt to reproduce typical clinical symptoms on HUT. Patients with cough syncope were compared with 29 age-matched control patients with syncope unrelated to coughing. A total of 29 patients (26 male, age 49 ± 14 years) with cough syncope were identified. Coughing during HUT reproduced typical prodromal symptoms of syncope in 16 (55%) patients and complete loss of consciousness in 2 (7%) patients, with a mean systolic blood pressure reduction of 45 ± 26 mmHg, and a mean increase in heart rate of 13 ± 8 b.p.m. No syncope or symptoms after coughing were observed in the control group. The HUT result was positive in 13 (48%) patients with the majority of positive HUT responses being vasodepressor (70% of positive HUT). Carotid sinus massage was performed in 18 patients being positive with a vasodepressor response causing mild pre-syncopal symptoms in only 1 patient. Syncope during coughing is a result of hypotension, rather than bradycardia. Coughing during HUT is a useful test in patients suspected to have cough syncope but in whom the history is not conclusive.

Venepuncture during head-up tilt testing in patients with suspected vasovagal syncope – implications for the test protocol.

Head-up tilt (HUT) testing is a widely used diagnostic tool in patients with suspected vasovagal syncope (VVS). However, no gold standard exists for this examination and the various protocols used have a limited sensitivity and specificity. Our aim was to determine the sensitivity of a sequential HUT testing protocol including venepuncture (VP) and sublingual nitroglycerin application. This was a retrospective analysis of the diagnostic gain of a sequential HUT testing protocol including VP applied 10 min after the start of HUT testing and sublingual application of nitroglycerin 20 min after the start of the test protocol in 106 patients with a final diagnosis of VVS. The sensitivity of the test protocol was compared between patients with positive and negative history for VP induced VVS. Overall, pre-syncope or syncope occurred in 68 patients (64.2%). Only 17% of all patients fainted spontaneously within 10 min of passive HUT. Another 39.6% fainted within 20 min. Application of nitroglycerin after 20 min of HUT evoked syncope in another 7.5% until the end of 45 min of HUT. The sensitivity of the test protocol for evoking (pre-)syncope was 94.4% in patients with a positive history for VP associated VVS and 58% in patients with a negative history (P < 0.01**); 85.7% of patients with a positive history and 42.9% of patients with a negative history fainted within 20 min of HUT testing (P < 0.01**). Implementation of VP in sequential HUT testing protocols allows the sensitivity of HUT testing to be increased, especially in patients with a positive history for VP associated VVS.

PW031 Assessment of baroreceptors function during head-up tilt test in patients with vasovagal syncope

PW031 Assessment of baroreceptors function during head-up tilt test in patients with vasovagal syncope