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  • • Evaluation of syncope of uncertain origin.

    • Evaluation of symptoms suggestive of autonomic dysfunction, such as

    • • Presyncope.

      • Atypical seizures.

      • Orthostatic symptoms.

    • Distinguish between psychosomatic and neurally mediated symptoms.

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  • • Complete heart block or profound bradycardia at rest.

    • Significant left or right ventricular outflow obstructive lesions.

    • Generally not performed in patients with structural heart disease and syncope, unless all other testing, including invasive electrophysiology testing, is unrevealing.

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  • • Tilt table: Motor-driven table, capable of 70-degree upright positioning.

    • Monitoring for continuous heart rate and blood pressure recording.

    • Intravenous access.

    • Resuscitation equipment, including medications and cardiac defibrillator.

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  • • Prolonged asystole.

    • Hypotension.

    • Seizures.

    • Cardiac arrest (very rare).

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  • • Most episodes of vasovagal or neurally mediated syncope can be elucidated by careful history of the events surrounding clinical episodes.

    • Tilt-table testing does not provide additional useful information for most straightforward cases of vasovagal syncope.

    • Tilt-table testing is helpful in the following settings:

    • • Recurrent syncope of uncertain etiology.

      • Syncope without prodromal symptoms.

      • Patients with normal electroencephalogram and a diagnosis of a seizure disorder.

      • Symptoms occurring while standing.

    • Patients with syncope should have an ECG performed to exclude possibility of long QT syndrome.

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  • • Patient should not have any oral intake for at least 4 hours before the study.

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  • • Initially supine.

    • Patient is secured to table with straps and given a footrest for support.

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  • • During standing, with decreased filling of ventricular chambers, C-reactive fibers in myocardium are stimulated and initiate afferent response to brain.

    • In response, neural reflex is initiated with drop in blood pressure or heart rate, or both.

    • Patients with neurally mediated syncope have profound decrease in blood pressure or heart rate or both, resulting in the following:

    • • Dizziness.

      • Nausea.

      • Headache.

      • Abdominal discomfort.

      • Syncope (often).

    • With profound hypotension or asystole, patient may experience seizure due to cerebral hypoperfusion.

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  • • Obtain intravenous access.

    • Monitor heart rate and blood pressure in baseline state while patient is supine.

    • Slowly raise table to 60–80-degree angle.

    • • Patient remains in this position for 15–60 minutes, depending on protocol.

      • Test is terminated promptly if significant symptoms develop.

    • Return the patient to the supine position at end of baseline testing or when significant symptoms develop.

    • Test may be repeated with pharmacologic challenge, usually isoproterenol infusion of 1–3 mcg/min.

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  • • Positive tilt-table responses to upright positioning trigger symptoms similar to clinical complaints.

    • The following responses describe positive responses:

    • • Vasodepressor response: Drop in systolic blood pressure.

      • Cardio-inhibitory response: Significant bradycardia.

      • Mixed response: Both drop in blood pressure and heart rate.

      • Postural tachycardia response: Increase in heart rate > 30 bpm during first 10 minutes of upright position.

      • Psychogenic: Cerebral vasoconstriction, without change in heart rate or blood pressure.

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  • • Occur rarely.

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