Autonomic Stress Test

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Caroline Short
10 years ago
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1 Autonomic Stress Test (The expanded head-up tilt test) Artur Fedorowski Syncope Unit Skåne University Hospital, Malmö, Sweden NordSync 2011, Malmö

2 Disclosure None

3 The expanded head-up tilt test When? Why? How? And what is the diagnosis?

4 Single syncope in high risk settings Recurrent syncope episodes To evaluate susceptibility to reflex syncope To discriminate between reflex and OH syncope To discriminate between syncope and epilepsy In unexplained falls

To discriminate between reflex and OH syncope To

5 The expanded head-up tilt test When? Syncopal attacks of uncertain etiology without clinical signs of underlying heart disease (ECG? Positive history or signs of structural heart disease?) Suspected orthostatic blood pressure instability Presyncopal attacks/vertigo if haemodynamic etiology is suspected or needs to be excluded Elderly patients who present with falls and amnesia

Positive history or signs of structural heart disease?

The expanded head-up tilt test Why? If you cannot catch it (syncopal attack), provoke it! Even if diagnosis is benign it can be important for patient s reassurance and coping skills.

6 The expanded head-up tilt test Why? If you cannot catch it (syncopal attack), provoke it! Even if diagnosis is benign it can be important for patient s reassurance and coping skills. It is the best way to evaluate circulatory response to standing and autonomic reflexes. Some diseases can only be diagnosed using this method. It is a non-invasive and safe procedure.

It is the best way to evaluate circulatory response to standing and autonomic reflexes.

7 The original stress test

8 It all started in 1986 Kenny et al,1986

10 HUT protocol Continuous BP and ECG monitoring Supine, cannulation, blood sample nr 1 after 15 min, Carotid sinus massage (CSM) in supine position (pos/neg) Head-up tilt and CSM if needed Tilt back, 5 min rest and head-up tilt nr 2 Blood sample nr 2 after 3 min Observation for 20±5 min (orthostatic response?/ vasovagal reflex?) GTN (glyceryl trinitrate) challenge if needed and observation for 15 min Initial (rapid) orthostatic response (under active rising) if needed

Blood sample nr 2 after 3 min Observation for 20±5 min (orthostatic response?/ vasovagal reflex?

12 Valsalva maneuver Goldstein et al. 2009

13 Initial orthostatic response to active standing Wieling et al, 2007

14 What is the HUT diagnosis?

15 Carotid sinus reflex: how does it work?

16 Carotid sinus hypersensitivity

17 Classical orthostatic hypotension

18 Delayed OH and vasovagal syncope

19 Neurocardiogenic (reflex) syncope sec

20 Postural (orthostatic) tachycardia syndrome

21 Syncope Unit, Malmö ~10 % No Dx

22 Take-home message By applying the expanded head-up tilt test with additional autonomic tests you will be able to effectively diagnose up to 80% of non-cardiac syncopal attacks (Fedorowski et al, 2010) Most frequently, you will find some variant of neurocardiogenic reflex such as vasovagal syncope or carotid sinus hypersensitivity among elderly patients (Brignole et al, 2006) Orthostatic blood pressure instability (hypotension or POTS) can be adequately diagnosed using this diagnostic tool (Gibbons et al, 2006; Grubb et al, 1997)

23 Thank you for your attention!

Assessment, diagnosis and specialist referral of adults (>16 years) with an episode of transient loss of consciousness (TLoC) or a blackout.

Assessment, diagnosis and specialist referral of adults (>16 years) with an episode of transient loss of consciousness (TLoC) or a blackout. TLoC is common huge variation in management range of clinicians