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The Value of Tilt Table Testing With Isoproterenol in Determining Therapy in Adults With Syncope and Presyncope of Unexplained Origin

The Value of Tilt Table Testing With Isoproterenol in Determining Therapy in Adults With Syncope... Abstract Background: Previous studies have shown the effectiveness of tilt table testing in establishing the diagnosis ofneurocardiogenic syncope and in dictating therapy in patients with syncope of unknown origin. Most studies have been limited by small numbers of patients and brief follow-up. Tilt table testing was performed with and without isoproterenol hydrochloride in 94 patients, and therapy was determined by the test findings. The patients were followed up for at least 10 months (mean, 17.8 months). Methods: The 80° tilt table test was performed in 94 consecutive patients who presented with syncope (n=74) or presyncope (n=20) and in whom neurologic and cardiac causes were ruled out. Therapy was determined by the tilt test findings. Sixty-seven patients were followed up for 17.8±5.3 months (mean±SD) (range, 10 to 27 months). Results: Forty-nine patients had positive results of tilt studies and received therapy. Of these 49 patients, 36 returned for second tilt studies while they were taking medication, and 30 had negative results. Six patients had medication changes and had negative results of follow-up tilt studies. No symptoms were noted on follow-up in the 24 patients who presented with syncope and who had positive results of tilt tests that responded to therapy. Of those 35 patients presenting with syncope who had negative results of initial tilt studies and who did not receive any therapy, syncope recurred in four patients. Three of 10 patients contacted who presented with presyncope and had negative results of tilt studies reported symptoms. Conclusions: Tilt table testing is an excellent tool for diagnosing neurocardiogenic syncope in adults and in determining effective therapy in patients presenting with syncope of unknown origin.(Arch Intern Med. 1994;154:1613-1617) References 1. Day SC, Cook EF, Funkenstein H, Goldman L. Evaluation and outcome of emergency room patients with transient loss of consciousness . Am J Med. 1982; 73:15-23.Crossref 2. Gendelman HE, Linzer M, Gabelman M, Smoller S, Scheur J. Syncope in general hospital patient population . N Y State J Med. 1983;83:1161-1165. 3. Savage DD, Corwin L, McGee DY, Kannel WB, Wolf PA. Epidemiologic features of isolated syncope: the Framingham study . Stroke . 1985;16:626-629.Crossref 4. Lipsitz LA, Wei JY, Rowe JW. Syncope in an elderly, institutionalized population: prevalence, incidence and associated risk . Q J Med. 1985;55:45-55. 5. Lipsitz LA, Pluchino FC, Wei JY, Rowe JW. Syncope in institutionalized elderly . J Chronic Dis. 1986;39:619-620.Crossref 6. Weissler AM, Warren JV. Review: vasodepressor syncope . Am Heart J. 1959; 57:786-794.Crossref 7. Vargas E, Rothwell C, Weinkove C, Lye M. The measurement of plasma noradrenaline before and after tilt in young and old healthy subjects . Gerontology . 1984;30:253-260.Crossref 8. Epstein SE, Stampfer M, Beiser GD. Role of capacitance and resistance vessels in vasovagal syncope . Circulation . 1968;37:524-533.Crossref 9. Weissler AM, Warren JV, Estes EH, McIntosh HD, Leonard JJ. Vasodepressor syncope: factors influencing cardiac output . Circulation . 1957;15:857-882.Crossref 10. Paley HW, McDonald IG, Blumenthal J, Mailhot J. The effects of posture and isoproterenol on the velocity of left ventricular contraction in man . J Clin Invest. 1971;50:2283-2294.Crossref 11. Murray RH, Bowers JA, Goltra ER. Comparison of footboard and saddle supports for orthostatic tests on a tilt table . J Appl Physiol. 1966;21:1409-1411. 12. Fitzpatrick A, Theodorakis G, Vardas P, et al. The incidence of malignant vasovagal syndrome in patients with recurrent syncope . Eur Heart J. 1991;12:389-394. 13. Grubb BP, Temsey-Armos P, Hahn H, Elliot L. Utility of upright tilt table testing in the evaluation and management of syncope of unknown origin . Am J Med. 1991;90:6-10.Crossref 14. Almquist A, Goldenberg IF, Milstein S, et al. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope . N Engl J Med. 1989;320:346-351.Crossref 15. Pongiglione G, Fish FA, Strasburger JF, Benson DW. Heart rate and blood pressure response to upright tilt in young patients with unexplained syncope . J Am Coll Cardiol. 1990;16:165-170.Crossref 16. Waxman MB, Yao L, Cameron DA, Wald RW, Roseman J. Isoproterenol induction of vasodepressor-type reaction in vasodepressor-prone persons . Am J Cardiol. 1989;63:58-65.Crossref 17. Milstein M, Buetikofer J, Dunnigan A, Benditt DG, Gornick C, Reyes WJ. Usefulness of disopyramide for prevention of upright tilt-induced hypotension-bradycardia . Am J Cardiol. 1990;65:1339-1344.Crossref 18. Almquist A, Goldenberg IF, Benson DW, Dunnigan A, Benditt DG. Provocation of bradycardia and hypotension by isoproterenol in patients with unexplained syncope . Circulation . 1986;74( (suppl II) ):32. Abstract. 19. Goldenberg IF, Almquist A, Dunbar DN, Milstein S, Pritzker MR, Benditt DG. Prevention of neurally mediated syncope by selective beta-1 adrenoreceptor blockade . Circulation . 1987;76( (suppl IV) ):133. Abstract. 20. Chen MY, Goldenberg IF, Milstein S, et al. Cardiac electrophysiologic and hemodynamic correlates of neurally mediated syncope . Am J Cardiol. 1989;63:66-72.Crossref 21. Sra JS, Anderson AJ, Sheik SH, et al. Unexplained syncope evaluated by EPS and head-up tilt testing . Ann Intern Med. 1991;114:1013-1019.Crossref 22. Sheldon R, Killiam S. Methodology of isoproterenol—tilt table testing in patients with syncope . J Am Coll Cardiol. 1992;19:733-739.Crossref 23. McCowan R, Tone L, Thorpe C, Kiser J, Miller T, Hatfield L. The use of head-up tilt table testing in the evaluation of unexplained syncope . W V Med J. 1992; 88:233-235. 24. Brignole M, Menozzi C, Gianfranchi L, Lolli G, Bottoni N, Oddone D. A controlled trial of acute and longterm medical therapy in tilt-induced neurally mediated syncope . Am J Cardiol. 1992;70:332-342.Crossref 25. Grubb BP, Wolfe D, Samoil D, et al. Recurrent unexplained syncope in the elderly: the use of head-upright tilt table testing in evaluation and management . J Am Geriatr Soc. 1992;40:1123. 26. Kapoor W, Brant N. Evaluation of syncope by upright tilt testing with isoproterenol: a nonspecific test . Ann Intern Med. 1992;116:358-363.Crossref 27. Murdock BD. Loss of consciousness in healthy South African men . S Afr Med J. 1980;57:771-774. 28. Williams RL, Allen PD. Loss of consciousness . Aerospace Med. 1962;33:545-551. 29. Dermksian G, Lamb LE. Cardiac arrhythmias in experimental syncope . JAMA . 1958;168:1623-1630.Crossref 30. Dermksian G, Lamb LE. Syncope in a population of healthy young adults . JAMA . 1958;168:1200-1207.Crossref 31. Kenny RA, Ingram A, Bayliss J, Sutton R. Head-up tilt: a useful test for investigation of unexplained syncope . Lancet . 1986;1:1352-1355.Crossref 32. Kapoor WN, Karpf M, Wieand S, Peterson JR, Levey GS. A prospective evaluation and followup of patients with syncope . N Engl J Med. 1983;309:197-204.Crossref 33. Shalev Y, Gal R, Tchou PJ, et al. Echocardiographic demonstration of decreased left ventricular dimensions and vigorous myocardial contraction during syncope induced by head-up tilt . J Am Coll Cardiol. 1991;18:746-751.Crossref 34. Abboud FM. Ventricular syncope . N Engl J Med. 1989;320:390-392.Crossref 35. Fitzpatrick A, Theodarakis G, Vardas P, Sutton R. Methodology of head-up tilt table testing in patients with unexplained syncope . J Am Coll Cardiol. 1991; 17:125-130.Crossref 36. Raviele A, Gasparini G, DiPede F, Delise P, Bonso A, Piccolo E. Usefulness of head-up tilt test in evaluating patients with syncope of unknown origin and negative EPS . Am J Cardiol. 1990;65:1322-1327.Crossref 37. Moazez F, Peter T, Simonson J, Mandel W, Vaughn C, Gang E. Syncope of unknown origin . Am Heart J. 1991;121:81-88.Crossref 38. Strasberg B, Sagie A, Rechavia E, Sclarovsky S. Noninvasive evaluation of syncope of suspected cardiovascular origin . Am Heart J. 1989;117:160-163.Crossref 39. Fitzpatrick A, Sutton R. Tilting towards a diagnosis in recurrent unexplained syncope . Lancet . 1989;1:658-660.Crossref 40. Abi Sambra F, Maloney JD, Fouad-Tarazi FM, Castle LW. The usefulness of head-up tilt testing and hemodynamic investigation in the work-up of syncope of unknown origin . Pace . 1988;11:1202-1214.Crossref 41. Strasberg B, Rechavia E, Sagie A, et al. The head-up tilt test in patients with syncope of unknown origin . Am Heart J. 1989;118:923-927.Crossref 42. Yao L, Cameron D, Rosemond J, Waxman MB. isoproterenol-induced vasodepressor reaction in man . Clin Invest Med. 1984;7:40. Abstract. 43. Nelson SD, Stanley M, Love CJ, Coyne KS, Schaal SF. The autonomic and hemodynamic effects of oral theophylline in patients with vasodepressor syncope . Arch Intern Med. 1991;151:2425-2429.Crossref 44. Sra JS, Murthy VS, Jazayeri MR, et al. Use of intravenous esmolol to predict efficacy of oral beta-adrenergic blocker therapy in patients with neurocardiogenic syncope . J Am Coll Cardiol. 1992;19:402-408.Crossref 45. McLaran CJ, Gersh BJ, Osborn MJ, et al. Increased vagal tone as an isolated finding in patients undergoing EP testing for recurrent syncope . Br Heart J. 1986;55:53-57.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

The Value of Tilt Table Testing With Isoproterenol in Determining Therapy in Adults With Syncope and Presyncope of Unexplained Origin

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Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1994.00420140079010
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Abstract

Abstract Background: Previous studies have shown the effectiveness of tilt table testing in establishing the diagnosis ofneurocardiogenic syncope and in dictating therapy in patients with syncope of unknown origin. Most studies have been limited by small numbers of patients and brief follow-up. Tilt table testing was performed with and without isoproterenol hydrochloride in 94 patients, and therapy was determined by the test findings. The patients were followed up for at least 10 months (mean, 17.8 months). Methods: The 80° tilt table test was performed in 94 consecutive patients who presented with syncope (n=74) or presyncope (n=20) and in whom neurologic and cardiac causes were ruled out. Therapy was determined by the tilt test findings. Sixty-seven patients were followed up for 17.8±5.3 months (mean±SD) (range, 10 to 27 months). Results: Forty-nine patients had positive results of tilt studies and received therapy. Of these 49 patients, 36 returned for second tilt studies while they were taking medication, and 30 had negative results. Six patients had medication changes and had negative results of follow-up tilt studies. No symptoms were noted on follow-up in the 24 patients who presented with syncope and who had positive results of tilt tests that responded to therapy. Of those 35 patients presenting with syncope who had negative results of initial tilt studies and who did not receive any therapy, syncope recurred in four patients. Three of 10 patients contacted who presented with presyncope and had negative results of tilt studies reported symptoms. Conclusions: Tilt table testing is an excellent tool for diagnosing neurocardiogenic syncope in adults and in determining effective therapy in patients presenting with syncope of unknown origin.(Arch Intern Med. 1994;154:1613-1617) References 1. Day SC, Cook EF, Funkenstein H, Goldman L. Evaluation and outcome of emergency room patients with transient loss of consciousness . Am J Med. 1982; 73:15-23.Crossref 2. Gendelman HE, Linzer M, Gabelman M, Smoller S, Scheur J. Syncope in general hospital patient population . N Y State J Med. 1983;83:1161-1165. 3. Savage DD, Corwin L, McGee DY, Kannel WB, Wolf PA. Epidemiologic features of isolated syncope: the Framingham study . Stroke . 1985;16:626-629.Crossref 4. Lipsitz LA, Wei JY, Rowe JW. Syncope in an elderly, institutionalized population: prevalence, incidence and associated risk . Q J Med. 1985;55:45-55. 5. Lipsitz LA, Pluchino FC, Wei JY, Rowe JW. Syncope in institutionalized elderly . J Chronic Dis. 1986;39:619-620.Crossref 6. Weissler AM, Warren JV. Review: vasodepressor syncope . Am Heart J. 1959; 57:786-794.Crossref 7. Vargas E, Rothwell C, Weinkove C, Lye M. The measurement of plasma noradrenaline before and after tilt in young and old healthy subjects . Gerontology . 1984;30:253-260.Crossref 8. Epstein SE, Stampfer M, Beiser GD. Role of capacitance and resistance vessels in vasovagal syncope . Circulation . 1968;37:524-533.Crossref 9. Weissler AM, Warren JV, Estes EH, McIntosh HD, Leonard JJ. Vasodepressor syncope: factors influencing cardiac output . Circulation . 1957;15:857-882.Crossref 10. Paley HW, McDonald IG, Blumenthal J, Mailhot J. The effects of posture and isoproterenol on the velocity of left ventricular contraction in man . J Clin Invest. 1971;50:2283-2294.Crossref 11. Murray RH, Bowers JA, Goltra ER. Comparison of footboard and saddle supports for orthostatic tests on a tilt table . J Appl Physiol. 1966;21:1409-1411. 12. Fitzpatrick A, Theodorakis G, Vardas P, et al. The incidence of malignant vasovagal syndrome in patients with recurrent syncope . Eur Heart J. 1991;12:389-394. 13. Grubb BP, Temsey-Armos P, Hahn H, Elliot L. Utility of upright tilt table testing in the evaluation and management of syncope of unknown origin . Am J Med. 1991;90:6-10.Crossref 14. Almquist A, Goldenberg IF, Milstein S, et al. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope . N Engl J Med. 1989;320:346-351.Crossref 15. Pongiglione G, Fish FA, Strasburger JF, Benson DW. Heart rate and blood pressure response to upright tilt in young patients with unexplained syncope . J Am Coll Cardiol. 1990;16:165-170.Crossref 16. Waxman MB, Yao L, Cameron DA, Wald RW, Roseman J. Isoproterenol induction of vasodepressor-type reaction in vasodepressor-prone persons . Am J Cardiol. 1989;63:58-65.Crossref 17. Milstein M, Buetikofer J, Dunnigan A, Benditt DG, Gornick C, Reyes WJ. Usefulness of disopyramide for prevention of upright tilt-induced hypotension-bradycardia . Am J Cardiol. 1990;65:1339-1344.Crossref 18. Almquist A, Goldenberg IF, Benson DW, Dunnigan A, Benditt DG. Provocation of bradycardia and hypotension by isoproterenol in patients with unexplained syncope . Circulation . 1986;74( (suppl II) ):32. Abstract. 19. Goldenberg IF, Almquist A, Dunbar DN, Milstein S, Pritzker MR, Benditt DG. Prevention of neurally mediated syncope by selective beta-1 adrenoreceptor blockade . Circulation . 1987;76( (suppl IV) ):133. Abstract. 20. Chen MY, Goldenberg IF, Milstein S, et al. Cardiac electrophysiologic and hemodynamic correlates of neurally mediated syncope . Am J Cardiol. 1989;63:66-72.Crossref 21. Sra JS, Anderson AJ, Sheik SH, et al. Unexplained syncope evaluated by EPS and head-up tilt testing . Ann Intern Med. 1991;114:1013-1019.Crossref 22. Sheldon R, Killiam S. Methodology of isoproterenol—tilt table testing in patients with syncope . J Am Coll Cardiol. 1992;19:733-739.Crossref 23. McCowan R, Tone L, Thorpe C, Kiser J, Miller T, Hatfield L. The use of head-up tilt table testing in the evaluation of unexplained syncope . W V Med J. 1992; 88:233-235. 24. Brignole M, Menozzi C, Gianfranchi L, Lolli G, Bottoni N, Oddone D. A controlled trial of acute and longterm medical therapy in tilt-induced neurally mediated syncope . Am J Cardiol. 1992;70:332-342.Crossref 25. Grubb BP, Wolfe D, Samoil D, et al. Recurrent unexplained syncope in the elderly: the use of head-upright tilt table testing in evaluation and management . J Am Geriatr Soc. 1992;40:1123. 26. Kapoor W, Brant N. Evaluation of syncope by upright tilt testing with isoproterenol: a nonspecific test . Ann Intern Med. 1992;116:358-363.Crossref 27. Murdock BD. Loss of consciousness in healthy South African men . S Afr Med J. 1980;57:771-774. 28. Williams RL, Allen PD. Loss of consciousness . Aerospace Med. 1962;33:545-551. 29. Dermksian G, Lamb LE. Cardiac arrhythmias in experimental syncope . JAMA . 1958;168:1623-1630.Crossref 30. Dermksian G, Lamb LE. Syncope in a population of healthy young adults . JAMA . 1958;168:1200-1207.Crossref 31. Kenny RA, Ingram A, Bayliss J, Sutton R. Head-up tilt: a useful test for investigation of unexplained syncope . Lancet . 1986;1:1352-1355.Crossref 32. Kapoor WN, Karpf M, Wieand S, Peterson JR, Levey GS. A prospective evaluation and followup of patients with syncope . N Engl J Med. 1983;309:197-204.Crossref 33. Shalev Y, Gal R, Tchou PJ, et al. Echocardiographic demonstration of decreased left ventricular dimensions and vigorous myocardial contraction during syncope induced by head-up tilt . J Am Coll Cardiol. 1991;18:746-751.Crossref 34. Abboud FM. Ventricular syncope . N Engl J Med. 1989;320:390-392.Crossref 35. Fitzpatrick A, Theodarakis G, Vardas P, Sutton R. Methodology of head-up tilt table testing in patients with unexplained syncope . J Am Coll Cardiol. 1991; 17:125-130.Crossref 36. Raviele A, Gasparini G, DiPede F, Delise P, Bonso A, Piccolo E. Usefulness of head-up tilt test in evaluating patients with syncope of unknown origin and negative EPS . Am J Cardiol. 1990;65:1322-1327.Crossref 37. Moazez F, Peter T, Simonson J, Mandel W, Vaughn C, Gang E. Syncope of unknown origin . Am Heart J. 1991;121:81-88.Crossref 38. Strasberg B, Sagie A, Rechavia E, Sclarovsky S. Noninvasive evaluation of syncope of suspected cardiovascular origin . Am Heart J. 1989;117:160-163.Crossref 39. Fitzpatrick A, Sutton R. Tilting towards a diagnosis in recurrent unexplained syncope . Lancet . 1989;1:658-660.Crossref 40. Abi Sambra F, Maloney JD, Fouad-Tarazi FM, Castle LW. The usefulness of head-up tilt testing and hemodynamic investigation in the work-up of syncope of unknown origin . Pace . 1988;11:1202-1214.Crossref 41. Strasberg B, Rechavia E, Sagie A, et al. The head-up tilt test in patients with syncope of unknown origin . Am Heart J. 1989;118:923-927.Crossref 42. Yao L, Cameron D, Rosemond J, Waxman MB. isoproterenol-induced vasodepressor reaction in man . Clin Invest Med. 1984;7:40. Abstract. 43. Nelson SD, Stanley M, Love CJ, Coyne KS, Schaal SF. The autonomic and hemodynamic effects of oral theophylline in patients with vasodepressor syncope . Arch Intern Med. 1991;151:2425-2429.Crossref 44. Sra JS, Murthy VS, Jazayeri MR, et al. Use of intravenous esmolol to predict efficacy of oral beta-adrenergic blocker therapy in patients with neurocardiogenic syncope . J Am Coll Cardiol. 1992;19:402-408.Crossref 45. McLaran CJ, Gersh BJ, Osborn MJ, et al. Increased vagal tone as an isolated finding in patients undergoing EP testing for recurrent syncope . Br Heart J. 1986;55:53-57.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 25, 1994

References