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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 2  |  Page : 43-48

The outcome of head up tilt test in older adults with typical versus atypical features of syncope


Department of Geriatrics, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission20-May-2022
Date of Decision11-Jun-2022
Date of Acceptance11-Jun-2022
Date of Web Publication15-Jul-2022

Correspondence Address:
Rakesh Mishra
Room No 262, Department of Geriatrics, Christian Medical College, Vellore - 632 002, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_22_22

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  Abstract 


Background: Syncope is usually a benign condition preventable by simple measures. Its diagnosis by history and inexpensive tests like head-up tilt table (HUTT) test save the patient unnecessary expenditure and stress. Objectives: To determine the outcome of head-up tilt test in older adult patients aged 60 years and more who present with typical versus atypical history of syncope, along with a study of the prodromal symptoms, association with comorbid burden, medications, grip strength, and cognitive function. Materials and Methods: An observational study of the patients presenting to the department of geriatrics with a history of neurocardiogenic syncope from May 2017 to October 2017 undergoing HUTT test looked at the association of the type of syncope based on the history and outcome of their HUTT test and association with prodromal symptoms, comorbidities, medications, triggering factors, electrocardiography, and Holter. Conclusions: The HUTT positivity rate for patients with a history of syncope was 31.8% with no association between typical or atypical syncope and HUTT positivity. Dizziness, lightheadedness, blurred vision, and sweating were significantly associated with typical syncope. No comorbidity or medication had an association with syncope or HUTT response but the comorbid burden had a significant association with positive HUTT response.

Keywords: Elderly, falls, neurocardiogenic, syncope, vasovagal


How to cite this article:
Mishra R, Mathews P, Gopinath K G. The outcome of head up tilt test in older adults with typical versus atypical features of syncope. J Indian Acad Geriatr 2022;18:43-8

How to cite this URL:
Mishra R, Mathews P, Gopinath K G. The outcome of head up tilt test in older adults with typical versus atypical features of syncope. J Indian Acad Geriatr [serial online] 2022 [cited 2022 Aug 18];18:43-8. Available from: http://www.jiag.com/text.asp?2022/18/2/43/351069




  Introduction Top


Syncope or fainting, falls, and dizziness are a major cause of morbidity and mortality in older adults. Syncope is defined as a sudden loss of consciousness associated with the inability to maintain postural tone, followed by spontaneous and complete recovery.[1]

Neurocardiogenic syncope (NCS), previously known as vasovagal syncope, is the most common type of syncope among neurally mediated syncope. The elderly population is more prone to NCS. The typical history of NCS includes three distinct phases: a prodrome or aura, loss of consciousness, and postsyncopal phase. Common precipitating factors include extreme emotional stress, anxiety, mental anguish, trauma, physical pain or anticipation of physical pain, warm environment, air travel, and prolonged standing.

A typical NCS is characterized by precipitating triggers like emotional distress or orthostatic stress and prodromal symptoms due to activation of the autonomic nervous system such as nausea, vomiting, abdominal discomfort, pallor, sweating, feeling cold or warm, palpitations, yawning, sighing, or urinary incontinence. The subject may have dizziness, lightheadedness, or blurred vision due to reduced blood supply to the reticular activating system of the brain or retina of the eye. The most common triggers in older individuals are prolonged standing and medications which can cause vasodilatation. The diagnosis of NCS may be suggested or made by a specific history with well-known triggers.

In patients with atypical syncope, the loss of consciousness occurs without warning symptoms. In the absence of a “gold standard” diagnostic test for NCS, an appropriate clinical history in association with a positive head-up tilt test currently provides the cornerstone for the diagnosis of NCS.


  Materials and Methods Top


This study was done in the Geriatrics Department of the Christian Medical College, Vellore, which is a tertiary care hospital in Tamil Nadu. It was a prospective cohort study done in 44 older adult patients. The study and methodology were approved by the institutional review board of Christian Medical College, Vellore (IRB MIN NO. 10573 dated March 8, 2017).

Subjects aged 60 years or more were recruited from the outpatient departments of Geriatrics and Cardiology according to the following eligibility criteria:

Inclusion criteria

  1. Subjects 60 years and above undergoing head-up tilt table (HUTT) in Christian Medical College, Vellore
  2. Subjects capable of giving informed consent
  3. Hemodynamically stable and ambulant patients.


Exclusion criteria

  1. Fragility/inability to stand
  2. Lower extremity fractures
  3. Severe anemia
  4. Recent stroke (within 6 months)
  5. Recent myocardial infarction (within 6 months)
  6. Severe proximal cerebral or coronary arterial disease
  7. Critical mitral or aortic stenosis
  8. End-stage renal failure
  9. Severe heart failure
  10. Advanced malignancy
  11. Dementia
  12. Autonomic dysfunction – Orthostatic hypotension.


All the patients who were included in the study had a history of transient loss of consciousness with spontaneous and complete recovery. The patients with benign paroxysmal positional vertigo (BPPV) usually do not have a loss of consciousness and were excluded based on a history of vertiginous symptoms associated with change in the position of head and also a positive Dix-Hallpike test or response to vestibular sedatives. Such patients with a clinical diagnosis of BPPV were not included in the study. However, the patients with vestibular syncope were not excluded.

The eligible patients were recruited as and when they came to the HUTT room in Christian Medical College, Vellore, from May 2017 to October 2017.

A detailed demographic assessment of all the participants was done including socioeconomic status of the patient based on the Urban Kuppuswamy socioeconomic scale. The other variables that were investigated were prodromal symptoms (specifically about the history of warmth, nausea, sweating, lightheadedness, blurred vision, dizziness, epigastric discomfort, and hot flashes), if there were triggers like emotional distress, orthostatic stress, pain, whether it was situational, the position in which most of their syncopal episodes occurred, comorbidities, Charlson comorbidity score, medications, cognition, functional status, and handgrip strength (using a Jamar Hand Dynamometer).

In the HUTT room of cardiology ward, the basic examination was done which included pulse, blood pressure which was checked in the supine position and the standing position at 1 and 3 min and change in blood pressure was assessed. A clinical examination of the cardiovascular system was done and clinical features of the left heart failure were noted, if any.

After this, a head-up tilt test was performed. In this, the patient was asked to report to the HUTT room in the cardiology ward, where, the patient was strapped to the HUTT table and a nurse started an intravenous line and connected the subject to monitors to record noninvasive blood pressure, heart rate, and continuous electrocardiogram (ECG). After 5 min of lying supine, the table was quickly turned to raise the body to a head-up position at seventy degrees, simulating a change from lying down to standing up. The table then remained upright for 20 min while the subject's heart rate, blood pressure, and ECG were monitored. After 20 min, 5 mg of sublingual sorbitrate was given and the table was kept upright for another 20 min. The test was considered positive if there was reproduction of the syncope and the patient had a transient loss of consciousness. In this case, the table was immediately made flat. Resuscitation kit and atropine injections were kept ready and the patient was constantly monitored by the principal investigator throughout the test. Based on the drop in heart rate, and blood pressure, the HUTT positive tests were classified according to the classification of the Vasovagal Syncope International Study.[2]

Mixed type

Heart rate falls at the time of syncope, but the ventricular rate does not fall to <40 beats/min, or falls to <40 beats/min for <10 s with or without asystole of <3 s. Blood pressure falls before the heart rate falls.

Cardioinhibitory type

Type IIA: Heart rate falls to a ventricular rate <40 beats/min for more than 10 s, but asystole of more than 3 s does not occur. Blood pressure falls before the heart rate falls.

Type IIB: Asystole occurs for more than 3 s. Heart rate fall coincides with or precedes blood pressure fall.

Vasodepressor type

The heart rate does not fall more than 10% from its peak value at the time of syncope basic blood tests, ECG, echocardiography, and a Holter monitoring were done for most patients as part of the basic workup for syncope. The management as advised by treating physician was collated from the medical report or the outpatient record.

As seen in the [Table 1], in this study, 6 of the 44 patients were females and all of them had presented with a history of typical syncope. Thus, in this study, female gender had a significant association with typical syncope. However, gender had no association with HUTT positivity.
Table 1: Clinical characteristics of the subjects

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The prodromes of warmth, sweating, lightheadedness, blurred vision, and dizziness were significantly associated with typical syncope. Only one patient had epigastric discomfort as a prodrome in this study. A history of orthostatic stress was also associated significantly with typical syncope. None of the patients in this study had pain or instrumentation as a triggering factor for syncope. A standing position was also significantly associated with typical syncope.

None of the comorbidities or medications studied had an association with either syncope or HUTT positivity. However, the Charlson comorbidity score had no association with typical syncope. Of the seven patients with a high Charlson comorbidity index, 5 had a positive HUTT response and the P value was significant. Thus, a statistically significant association was found between a high Charlson comorbidity index and HUTT positive response. In addition, there was no significant association between cognitive impairment and handgrip strength with either a history of syncope or HUTT response. ECG and Holter also did not have a significant association with either type of syncope or HUTT positivity.

Type I was found to be the most common response in this study, but the type of response was not found to have an association with the type of syncope.

None of the 14 patients who had a positive HUTT response had any complication requiring hospitalization and all had a spontaneous and complete recovery. Thus, in our study, it was found to be safe in the elderly.

In the multivariate analysis, we found that blurred vision and dizziness had a significant association as prodrome for a history of typical syncope as per [Table 2]. However, a multivariate analysis with HUTT response did not show any association of any prodrome with a HUTT positive response.
Table 2: Multivariate analysis for typical syncope

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  Discussion Top


Since syncope is a common cause of falls and transient loss of consciousness, and in the lack of a gold standard for diagnosis of syncope, history, and HUTT test form the cornerstones for the diagnosis. It is imperative to rule out abnormalities of cardiac structure, function, and rhythm. Usually, the evaluation of transient loss of consciousness is very expensive and in the absence of an adequate and good history and clinical examination, it may entail ordering expensive tests including magnetic resonance imaging, electroencephalography, and loop recorders. Hence, if a diagnosis of NCS is made on the basis of history and inexpensive tests like HUTT, it saves the patient time and money. Furthermore, in view of a good prognosis of NCS and effective strategies to prevent an episode, it also prevents undue distress to the patient.

In a study done by Bloomfield et al. which looked at the effects of age on the outcome of head-up tilt testing, a decline was found in the positivity of tilt-table test with age. It was 55% in the group of <40 years of age, 50% in the age group 40% to 64%, 39% in 65–79 years and 23% in subjects more than 80 years of age. This age-related decline was seen in both males and females.[3] In our study, this age-related decline in HUTT positivity was not seen as 26.48% of patients in the age group of 60–70 years were HUTT positive and 50% of patients in the age group of 70–80 years were HUTT positive.

Typical syncope is characterized by the presence of antecedent premonitory symptoms, the most important of which were evaluated in this study.

In a study by Sheldon et al., it was found that the features of history that were contributory to tilt-positive primary syncope diagnosis were exposure to pain or a medical procedure, warmth or diaphoresis, and association with prolonged standing or sitting.[4] In another study, the most commonly reported prodromal signs and symptoms were pallor, dizziness, and diaphoresis. Furthermore, typical features of syncope were less common in males and the elderly.[5] However, in our study, no significant association between any of these prodromes was found with a positive response to HUTT test. Like this study, our study also had an atypical presentation in males and all the females had typical syncope.

In our study, of the prodromal symptoms evaluated, the symptoms of sweating, lightheadedness, blurred vision, and orthostatic stress had statistically significant associations with typical syncope in the univariate analysis and the prodrome of warmth approached statistical significance. In a multivariate analysis, the prodromes of blurred vision and dizziness had statistically significant association with typical syncope.

In our study, the most common comorbidity was found to be hypertension with 65.91% of the patients being hypertensives. The next most common comorbidity was dyslipidemia being present in 50% of the patients followed by diabetes mellitus (31.82%), ischemic heart disease (15.91%), chronic obstructive pulmonary disease (6.82%), and cerebrovascular accident (4.55%).

The most commonly used group of medications was found to be angiotensin-converting enzyme inhibitors/angiotensin receptor blockers as 54.55% of the patients were on the same. This was followed by diuretics (22.73%), calcium channel blockers (20.45%), beta-blockers (13.64%), benzodiazepines and antidepressants.

None of these comorbidities or medications had a significant association with a positive HUTT response or a history of typical syncope.

A study was done by Paul et al. to assess the influence of medication use and comorbidities on the outcome of the tilt table test in patients in the geriatric age group found that the tilt table test outcome was uninfluenced by comorbidities or medications.[6] With regard to the comorbidities and medications, our study too had no association with HUTT response.

There was no significant association of a high Charlson comorbidity index with a history of typical syncope. But of the 7 patients with a high Charlson comorbidity index, 5 had positive HUTT response and this was statistically significant with a P = 0.047. No data in literature was found in this regard.

The risk of cognitive decline and falls increases with advancing age. Hence, this study also looked at the association between syncope, HUTT positivity, and cognitive decline. The test used was a mini cog test which is a short screening test of cognition. In our study, according to this screening tool, 27.27% of the patients were found to be positive for cognitive decline but did not have a significant association with typical syncope or a HUTT-positive response. A thorough literature search was done but we did not come across a study showing the association of cognition with syncope.

A low handgrip strength is a marker of frailty which is another risk factor for falls. Our study also found that the grip strength was not associated with a history of typical syncope or a positive HUTT response. Literature search did not reveal any study done on handgrip in relation with syncope.

A study done by Raviele et al. which was a comparative study of diagnostic accuracy of sublingual nitroglycerin and low-dose isoproterenol in 71 patients with unexplained syncope without organic heart disease and thirty control subjects who were asymptomatic it was found that with sublingual nitroglycerin, the positivity rate was 49%.[7]

In our study, of the 44 patients in the study presenting with a history of syncope, 14 were positive for HUTT which was 31.81% positivity rate.

Of the 14 patients who had HUTT positive response in this study, 8 had a history of typical syncope and 6 had atypical syncope. The most common response was Type 1 (42.86%) followed by Type 3 (28.57%), Type 2B (21.43%), and Type 2A (7.14%). There was no association of typical syncope with any type of HUTT response.

The findings of our study were different from a study done to assess the efficacy of tilt training in patients with vasovagal syncope in which, 40 patients with recurrent vasovagal syncope received tilt training using the tilt table. In this study, a Type 1 or mixed response was found in 17 patients (42.5%), Type 2 or cardioinhibitory response was found in 22 patients (55%), and a Type 3 or vasodepressive response was found in one patient (2.5%).[8]

This difference could be due to different patient profiles in the two studies.

A majority of the patients had a normal ECG (81.4%) and no association was found between ECG changes and typical syncope or HUTT response.

In all, 35 of the 44 patients in the study had undergone a Holter test. 22.86% of these patients had an abnormal response on Holter. No significant association was found between abnormal Holter and typical syncope. Although a larger proportion of patients with Holter positivity also had a positive response on HUTT, this association was not found to be statistically significant.

Thus, our study highlights the need for a good history and targeted tests and avoid unnecessary tests to diagnose NCS in older adults since the yield of these tests is low and adds to the cost.[9]


  Conclusions Top


  1. The HUTT positivity for patients with a history of syncope was 31.8%
  2. Among the HUTT responses, Type 1 response was the most common in our study
  3. There was no significant difference between typical and atypical syncope for HUTT positivity
  4. Among the prodromal symptoms, dizziness, lightheadedness, blurred vision, and sweating had a significant association with typical syncope but not with HUTT positivity
  5. Among the triggering factors prolonged orthostatic stress and standing position had a significant association with typical syncope
  6. Although none of the comorbidities had statistically significant association with either typical syncope or HUTT positivity, the comorbid burden as measured by the Charlson comorbidity index had a statistically significant association with a positive response to HUTT test
  7. A good history is of paramount importance in the diagnosis of syncope.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS); Moya A, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30:2631-71.  Back to cited text no. 1
    
2.
Brignole M, Menozzi C, Del Rosso A, Costa S, Gaggioli G, Bottoni N, et al. New classification of haemodynamics of vasovagal syncope: Beyond the VASIS classification. Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study. Europace 2000;2:66-76.  Back to cited text no. 2
    
3.
Bloomfield D, Maurer M, Bigger JT Jr. Effects of age on outcome of tilt-table testing. Am J Cardiol 1999;83:1055-8.  Back to cited text no. 3
    
4.
Sheldon R, Rose S, Connolly S, Ritchie D, Koshman ML, Frenneaux M. Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur Heart J 2006;27:344-50.  Back to cited text no. 4
    
5.
Romme JJ, van Dijk N, Boer KR, Dekker LR, Stam J, Reitsma JB, et al. Influence of age and gender on the occurrence and presentation of reflex syncope. Clin Auton Res 2008;18:127-33.  Back to cited text no. 5
    
6.
Paul B, Gieroba Z, Mangoni AA. Influence of comorbidities and medication use on tilt table test outcome in elderly patients. Pacing Clin Electrophysiol 2007;30:540-3.  Back to cited text no. 6
    
7.
Raviele A, Giada F, Brignole M, Menozzi C, Marangoni E, Manzillo GF, et al. Comparison of diagnostic accuracy of sublingual nitroglycerin test and low-dose isoproterenol test in patients with unexplained syncope. Am J Cardiol 2000;85:1194-8.  Back to cited text no. 7
    
8.
Gajek J, Zyśko D, Mazurek W. Efficacy of tilt training in patients with vasovagal syncope. Kardiol Pol 2006;64:602-8.  Back to cited text no. 8
    
9.
Johnson PC, Ammar H, Zohdy W, Fouda R, Govindu R. Yield of diagnostic tests and its impact on cost in adult patients with syncope presenting to a community hospital. South Med J 2014;107:707-14.  Back to cited text no. 9
    



 
 
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  [Table 1], [Table 2]



 

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