Tilt Table Testing for Evaluation of Neurally-Mediated (Cardioneurogenic) Syncope: Rationale and Proposed Protocols

Sympathetic vasoconstrictor impulses were recorded with microelectrodes in peroneal muscle nerve fascicles during vasovagal syncope in two subjects. After a preceding period of increased nerve activity, onset of syncope was associated with bradycardia and sudden cessation of sympathetic outflow. The findings provide direct evidence that neurally mediated muscular vasodilatation occurring during syncope is due to inhibition of vasoconstrictor impulses.

To enhance the clinical evaluation of patients suffering from recurrent syncope of unknown origin, the integrity of mechanisms controlling blood pressure was examined in 151 patients utilizing a screening tilt test. Ninety-eight patients had an abnormal blood pressure and/or heart rate response to tilt testing, including provoked syncopal attacks in 63 patients. Whenever indicated, the screening tilt test was followed by blood volume and hemodynamic determinations, as well as autonomic nervous system testing to identify contributing pathophysiological abnormalities (hypovolemia, venous pooling, autonomic dysfunction). Detailed analysis of this battery of tests allowed us to conclude that: (1) The tilt test is commonly a provocative tool in the workup of patients with recurrent syncope due to vasovagal - vasodepressor reactions and other abnormalities of blood pressure regulation; (2) Its usefulness is augmented by associated hemodynamic and blood volume evaluations; (3) The identification of contributory pathophysiological mechanisms of blood pressure control facilitates specific therapeutic interventions.