Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness
EFAS/EAN · 2021 · Europe
Source and licence
- Authors
- Roland D. Thijs, Michele Brignole, Cristian Falup-Pecurariu et al.
- Title
- Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness
- Journal
- Clinical Autonomic Research, 2021
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC8184725
Licence statement of the original publication
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
TTT should be considered
- To increase the probability of a diagnosis of reflex syncope This holds for those in whom the initial evaluation, including history taking, ECG, and supine and standing blood pressure measurements raised a suspicion but not a definite or highly likely (probability 80–100%) diagnosis, or in those in whom confirmation of a diagnosis is required for other purposes, such as convincing patients, parents or medicolegal requirements.
- To assess classic OH and delayed OH The recommended screening test for classic OH is a bedside active standing test with conventional intermittent BP measurements. TTT or an active standing test with continuous BP measurements should be considered if the bedside test does not show classic OH while the symptoms suggest classic OH (Table 2) [2]. TTT is particularly useful in detecting delayed OH, i.e. those with a sustained blood pressure fall of the magnitude of classic OH, but occurring later than 3 min upon standing [3, 22]. TTT may also be used to diagnose classic OH in subjects for whom active standing is difficult or unlikely to succeed, such as frail elderly and patients with significant motor impairments.
- To support a clinical diagnosis of POTS [3, 37] Documentation of an exaggerated postural tachycardia using TTT or an active standing test may support a clinical diagnosis of POTS.
- To differentiate between syncope with myoclonus (‘convulsive’ syncope) and tonic–clonic seizures [38].
- To discriminate between neurogenic and non-neurogenic classic OH A blunted heart rate increase during classic OH makes a neurogenic cause more likely. A ΔHR/ΔSBP ratio < 0.5 bpm/mmHg argues for neurogenic OH [27].
- To differentiate between vasovagal syncope and psychogenic TLOC [39, 40].
- To study the timing between asystole and the onset of TLOC Asystole in VVS may occur too late to have been the prime cause of TLOC, making pacemaker implantation likely ineffective [36].
- To teach patients with reflex syncope and orthostatic hypotension to recognise hypotensive symptoms and how to perform physical counter manoeuvres [33, 34].
TTT should not be used
- To evaluate the treatment of reflex syncope TTT should not be used for the routine clinical evaluation of treatment efficacy, although it might have a role in the evaluation of treatment approaches for reflex syncope in the research context [2, 11].
- To exclude cardiac syncope Syncope during TTT suggests the presence of hypotensive susceptibility. This tendency is common and modulates the occurrence not only of orthostatic VVS, but also of other forms of syncope such as cardiac syncope [14].
- To exclude VVS The sensitivity of TTT, especially TTT without pharmacological provocation, is too low to exclude VVS [14, 15].
Indications for additional provocations and measurements
- The committee recommends that additional provocations and measurements are tailored to the patient's needs. Figure 3 provides guidance as to when these auxiliary measures could be considered. Recommendations for TTT protocols and supplementary measurements are summarised in Table 3 and detailed in the following section.
Abstract
An expert committee was formed to reach consensus on the use of tilt table testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous events. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to the performance of (1) additional provocation tests, such as the active standing test, carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; and (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.
Contents of the original publication
The section headings of the original.
- Introduction
- Indications
- To obtain a pathophysiological correlate for orthostatic intolerance and TLOC
- To classify classic OH
- Treatment
- Indications for additional provocations and measurements
- Equipment
- Basic equipment
- Equipment extensions
- TTT protocols
- Classic TTT
- TTT: possible extensions and variants
- Patient information
- Safety
- Clinical environment
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