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TILTTABLE TESTING
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Syncope is defined as a sudden, brief transient loss of consciousness ... RESUSCITATION TROLLEY AVAILABLE ALWAYS. TESTS ARE DONE IN THE CARDIO-RESPIRATORY DEPT. ... – PowerPoint PPT presentation
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Title: TILTTABLE TESTING
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TILT-TABLE TESTING CAROTID SINUS
HYPERSENSITIVITY
- BELLA RICHARD
- ASSOCIATE SPECIALIST
- NEVILL HALL HOSPITAL
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- Syncope is defined as a sudden, brief transient
loss of consciousness associated with loss of
postural tone with spontaneous recovery - Syncope is a big problem
- Great cause of anxiety among patients, carers and
treating physicians - 3 AE visits annually
- 6 hospital admissions annually
- May be the only warning episode before sudden
cardiac death. - Common cause of unexplained elderly falls
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CAUSES OF SYNCOPE
- CVS -13.2
- UNKNOWN CAUSES -31
- STROKE/TIA - 4.3
- SEIZURE DISORDER - 7.2
- VASOVAGAL - 20
- ORTHOSTATIC CAUSE -9
- MEDICATION -6.3
- OTHER CAUSES -9.5
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TILT TABLE TESTING
- Ancient test-used in experiments to study bodys
response to posture - Since 1986- used as an evaluation tool for
syncope - Now gold-standard
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PHYSIOLOGICAL BASIS
- On standing 300-800mls of blood is displaced
downwards - In seconds mechano-receptors in the vasculature
compensate by increasing sympathetic tone -
vasoconstriction and increased cardiac output - Orthostatic stabilisation occurs within 60 secs
- Neurally mediated response
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- Tilt table test examines this neuro-cardiovascular
response in a maximally controlled environment. - Tilt angle -700 angle of maximal passive
orthostatic stress - Tilt duration 10min supine followed by 40 min
tilted. - ?pharmacological stimulation- nitroglycerine,
isoproterenol, epinephrine ( increases
sensitivity at the expense of specificity)
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INDICATIONS AND CONTRA INDICATIONS FOR HUT
- INDICATIONS -, RECURRENT SYNCOPE OR PRESYNCOPE
- SINGLE SYNCOPE WITH SERIOUS CONSEQUENCES
- AUTONOMIC FUNCTION TESTS
- SITUATIONAL SYNCOPE
- OH
- POTS
- CAROTID SINUS HYPERSENSITIVITY.
- CONTRAINDICATIONS - SEVERE LV OUTFLOW
OBSTRUCTION, SEVERE CORONARY /CAROTID STENOSIS
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Five responses
- Neurocardiogenic syncope symptomatic sudden
drop in BP after 10 mins associated with
bradycardia. - These patients are well between turns.
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- Dysautonomic response - gradual
decrease in BP to a hypotensive level leading to
LOC. HR will not rise significantly. - These patients have other features like abnormal
sweating, thermal intolerance, bowel symptoms. - POTS - mild form of autonomic dysfunction in
which excessive increase in HR cannot compensate
for low peripheral vascular resistance. Patients
increase HR to gt30/min in 10 min of upright
posture
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- Patients have near syncope, palpitations, fatigue
- Cerebral syncope - Research centres doing TTT and
transcranial dopplers found a small number of
patients having cerebral vasoconstriction with no
hypotension and bradycardia. - Psychogenic or psychosomatic response - patient
has vague symptoms but no findings. Patients
often have coexisting psychiatric disorders.
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CAROTID SINUS HYPERSENSITIVITY.
- COMMON CAUSE OF SYNCOPE IN ELDERLY PATIENTS
- UNDIAGNOSED IN UPTO 50 OF PATIENTS.
- NOT EASILY REPRODUCIBLE.
- NEEDS REPEATED TESTING TO ENSURE PICK UP.
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- POSITIVE TEST COULD BE
- VASODEPRESSOR,
- CARDIOINHIBITORY OR A
- MIXED RESPONSE.
- DIAGNOSE IF gt 3SECS ASSYSTOLE OR 50 MM HG DROP
IN SYSTOLIC BP. - DUAL CHAMBER PACING IN THESE PATIENTS PRODUCES
SYMPTOMATIC RELEIF IN 90 PATIENTS. - OVERLAP EXISTS BETWEEN CSH AND VASOVAGAL
SYNCOPE.
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INDICATIONS AND CONTRAINDICATIONS FOR CSM
- INDICATIONS - OLDER PATIENTS WITH SYNCOPE ,
UNEXPLAINED FALLS - CONTRAINDICATIONS - TIA / MI /STROKE IN THE PAST
3 MONTHS - PREVIOUS VF ARREST
- CAROTID BRUITS / CAROTID STENOSIS gt 70
- LESS SEVERE CAROTID STENOSIS ONLY SUPINE CSM
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PROTOCOLS
- PASSIVE DRUG FREE TILT
- 40 MIN AT 70 DEGREES HEAD UP TILT
- REST PATIENT FOR 20 MIN PRIOR TO TESTING
- CAROTID SINUS MASSAGE BEFORE TILTING AND AFTER 40
MIN HEAD UP TILT - CONSENT OBTAINED FOR CAROTID SINUS MASSAGE
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Staffing levels
- TWO OPERATORS MUST BE PRESENT OF WHICH ONE MUST
BE TRAINED IN ACLS - RESUSCITATION TROLLEY AVAILABLE ALWAYS
- TESTS ARE DONE IN THE CARDIO-RESPIRATORY DEPT.
- ONE AFTERNOON SESSION PER WEEK
- NOT MORE THAN THREE PATIENTS PER SESSION
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Syncope in the Older AdultDiagnostic Evaluation
- Pursue witness accounts when possible
- Include in history taking
- social circumstances, injurious events, impact of
events on confidence, ability to perform ADLs
independently - Determine timing of syncope occurrence
- orthostatic hypotensive events usually occur in
the AM - Association with meals, medications, nocturnal
micturition, etc. - Detailed medication history
- Co-morbid diagnoses (especially Parkinsons,
diabetes, anaemia, hypertension, ischaemic heart
disase, heart failure)
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Syncope in the Older AdultExamination
- Assessment of neurological and locomotor systems
- Including observation of gait and standing
balance (eyes open eyes closed) - Determine if cognitive impairment is present
(mini-mental state examination)
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Syncope in the Older AdultInvestigations
- The diagnostic evaluation should include the same
basic components as for younger adult - Exception is routine supine and upright carotid
sinus massage - Repeated morning measurements are recommended to
determine if orthostatic hypotension exists - 24-hr ambulatory BP may be helpful if meals or
medications are suspected - If symptoms continue, or gt 1 cause is suspected,
further evaluation is indicated
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Syncope in the Older AdultEvaluation of the
Frail and Elderly
- The rigour of assessment should depend on
compliance with tests and on prognosis - For patients who have difficulty standing
unaided, head-up tilt can be used to assess
orthostatic changes - Clinical decisions regarding the value of a
syncope evaluation should be made for each
patient based on the benefits to the individual
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Syncope in the Older AdultConclusions
- Class I Recommendations
- Morning orthostatic blood pressure measurements
and supine and upright carotid massage are
integral to the initial evaluation unless
contraindicated. - The evaluation of mobile, independent,
cognitively normal older adults is as for younger
individuals. - In frailer older adults, evaluation should be
modified according to prognosis.
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CASE 3
- 74 yr old lady
- 3 blackouts, always in church!
- 24 hr ECG normal.
- No postural BP deficit.
- Subjected to tilting Jan 2002.
- CSM supine - NAD.
- 30 min hut did not produce any change in HR or
BP. - CSM at the end of tilting time produced 4.2 SEC
pause - Also hypotension bp decreased from 137/78 to
88/59. - Patient had syncope!
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CASE 2
- Mrs IT, 69 yr lady with recurrent blackouts.
- Seen by ENT ?right hearing loss ?Cause
- Seen by neurologist ?cerebrovascular disease. MRI
brain confirmed deep white matter lesions /small
vessel ischaemia. - Still continuing to have black outs
- 24 hour ECG normal.
- Subjected to tilt table test in nov 2001
- Carotid sinus massage nad
- 18 minutes into tilting heart rate dropped to
48/min, BP dropped to 76/34 and patient lost
consciousness. - Recovered on assuming supine position.
- ?Neurocardiogenic syncope.
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- Commonest cause of syncope in all age groups.
- Underdiagnosed problem.
- Characterised by bradycardia, hypotension or both
during symptoms. - In normal individuals- upright position increases
venous pooling, this leads to increase in heart
rate and compensatory vasoconstriction.
Underfilled ventricle then contracts vigorously
and thus activates the afferent mechanoreceptors. - In patients with NCS- this rapid increase in
afferent neural activity produces a centrally
mediated paradoxical decrease in heart rate and
peripheral vasodilatation leading to hypotension. - Tilt table testing is the investigation of choice.
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TREATMENT
- Medical management-
- Beta blockers- supresses response to circulating
catecholamines - Theophyllines- as above.
- Fludrocortisone- volume expansion
- SSRI- central acting- modifies the baroreceptor
response. - Midodrine- a specific adrenergic receptor agonist
with low side effect profile. It binds to
peripheral receptors and increases vascular tone. - Pacemakers-for patients with predominant
cardioinhibition.
