Tilt Table Test

Muahammad Naveed Saeed CVTSarfraz Nawaz CVT

10-Novemebre-2016

• A tilt table test is used to evaluate the cause of unexplained fainting (syncope).

• It is widely used in making the diagnosis of Neurally Mediated Syncope.

Neurally mediated Syncope (NMS)

Transient loss of consciousness and postural tone with spontaneous recovery.

Other names:• Vasovagal syncope.• Reflex syncope.• Common faint.

Nervous system

• HR and BP= rise and fall• Control = Sympathetic & parasympathetic NS• Sympathetic nerves =↑ HR & BP• Parasympathetic nerves = ↓HR & BP

continued

• Driving normally.• Goes fast.• Hit the brakes too hard• Becomes very slow that can not meet the

requirements. (blood supply to the brain stops)

How does it happen?

• Standing for long time.• Venous pooling.• ↓ in blood volume.• Sympathetic ↑ & → HR+BP↑• Parasympathetic activates & ↓ HR+BP

commonly.• But in people with NMS overdrive of

parasympathetic occurs & ↓↓↓ HR & ↓↓↓BP.

Syncope can be from

• Dehydration.• Long time standing.• Pain• Stress• Exercise.

Indications

• History of episodes of fainting or loss of consciousness.

• Hypotension (unexplained)• Tachycardia when standing• Pallor when upright• Dizziness (unexplained)• Lightheadedness• History of frequent unexplained falls.

Contraindications

• Severe anemia• Recent stroke (within seven days)• Recent myocardial infarction• Severe proximal cerebral or coronary arterial disease• Critical mitral or aortic stenosis• Left ventricular outflow tract obstruction• Tachyarrhythmias• End-stage renal failure• Severe heart failure

Preparation

• NPO for 12 to 14 hours.(?)• Take necessary medications with a small sip of

water.• No diabetic medications.

TTT is used to evaluate syncope

Set-up

• Disinfect and clean the skin before placing the electrode. (no petroleum ether)

• Open the flaps of the blue clips and insert the narrow end of the electrode fully into the clip.

• While inserting keep the illustration with Head up.

ICG Electrodes

• Place two of the three ICG electrodes at the lateral side of the thorax at xiphoid-level.

Neck electrode

• Place the third electrode on the neck between hair line and shoulder.

• Make sure that there is no hair under the electrode and That it does not crease.Note: Do not mix the neckAnd thorax electrodes.

• Place the neutral electrode on the left leg or hip.

• The ECG electrodes are placed as usual to get a high resolution ECG.

Finger cuff• Choose the appropriate finger cuff out of the sizes small, medium and large.• The cuff should not be too tight or too loose

as this influences the signal quality.• Place the finger cuff on two fingers.

• Fasten the vascular unloading module to the forearm using the black velcro cuff.• Connect the finger cuff to the vascular unloading module.• All connectors are pushed in and pulled out NEVER TWIST the connectors.• Ensure that the two air hoses do not cross one another.

Upper arm cuff• Select the upper arm cuff according to the

circumference of the patient’s upper arm. small adult=17-25cm,adult=23-33cm large adult=31-40cm.• Place the cuff on the upper arm with the artery arrow mark directly above the brachial artery.

Complete set-up

Tips for Measurement

• If the beat to beat blood pressure signal can not be detected, try a change of fingers or warming the hand in warm water can help.

• Avoid movements of hands, fingers or arms during the measurement.

• Use the arm sling.

Medication used during the test

• Nitroglycerine → venous pooling, ↓volume. ↑sympathetic and ↑HR then syncope episode occurs .

• Isoprel → ↑HR+↑BP and then a reflex ↑ in parasympathetic.

Classification of Positive Responses to Tilt Testing

• Type 1 (Mixed).Heart rate falls at the time of syncope, but the ventricular rate does not fall to less than 40 beats/min-1 or falls to less 40 beats/min-1 for less than 10 s with or without asystole of less than 3 s. Blood pressure falls before the heart rate falls.

• Type 2 – CardioinhibitoryA) Cardioinhibition without asystole: heart rate falls to a ventricular rate less than 40 beats/min-1 for more than 10 s, but asystole of more than 3 s does not occur before the heart rate falls.

B) Cardioinhibition with asystole: Asystole occurs for more than 3 s. Blood pressure falls with or occur before the heart rate fall.

• Type 3 – VasodepressorHeart rate does not fall more than 10% from its peak at the time of syncope.Exception 1. Chronotropic incompetence: No heart rate rise during the tilt testing (ie, less than 10% from the pre-tilt rate).Exception 2. Excessive heart rate rise: An excessive heart rate both at the onset of the position and throughout its duration before syncope (ie, greater than 130 beats/min-1).

complications

• If test Is positive.Lower the table immediatelyKeep the legs upReplace IV fluidsIf severe Brady then injection atropine.

Management

• Very common• 1:20• Not dangerous• ↑ oral fluids (with salt)• Lie down immediately.• Medicines to increase the BP

Any Questions?