Neurally mediated hypotension and bradycardia are believed to be common causes of syncope. We used the "upright-tilt test" (duration, less than or equal to 10 minutes) with or without an infusion of exogenous catecholamine (isoproterenol [1 to 5 micrograms per minute], given intravenously) to elicit bradycardia, hypotension, or both in 24 patients with recurrent syncope and in 18 control subjects. A conventional electrophysiologic test performed before the tilt test was positive in 9 of the 24 patients, revealing arrhythmias that may have caused recurrent syncope, but was negative and thus nondiagnostic in 15 patients. The tilt test alone (i.e., without isoproterenol) induced symptomatic bradycardia or hypotension in 1 of the 9 patients with positive electrophysiologic tests (11 percent), 4 of the 15 patients with negative electrophysiologic tests (27 percent), and none of the controls. When the isoproterenol infusion was administered during the tilt test, 9 of the 11 patients with negative electrophysiologic and tilt tests had syncope, marked slowing of the heart rate, and hypotension. In contrast, isoproterenol was associated with tachycardia and only a slight decline in arterial pressure in the 8 remaining patients with positive electrophysiologic tests and the 18 control subjects, and syncope developed in only 1 of the 8 patients with positive electrophysiologic tests and negative tilt tests (13 percent) and 2 of the 18 control subjects (11 percent). We conclude that an isoproterenol infusion administered in conjunction with the upright-tilt test may be useful for identifying susceptibility to neurally mediated recurrent syncope.
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Department of Medicine, University of Minnesota Medical School, Minneapolis.
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(2001). Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J
22: 1256-1306
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Olshansky, B.
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86: 859-868
[Abstract][Full Text]
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(2001). Variations in diagnostic yield of head-up tilt test and electrophysiology in groups of patients with syncope of unknown origin. Eur Heart J
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(2001). Comparison of provocative tests for unexplained syncope: isoprenaline and glyceryl trinitrate for diagnosing vasovagal syncope. Eur Heart J
22: 497-503
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Madrid, A. H., Ortega, J., Rebollo, J. G., Manzano, J. G., Segovia, J. G., Sanchez, A., Pena, G., Moro, C.
(2001). Lack of efficacy of atenolol for the prevention of neurally mediated syncope in a highly symptomatic population: a prospective, double-blind, randomized and placebo-controlled study. J Am Coll Cardiol
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(2001). The fainting patient: value of the head-upright tilt-table test in adult patients with orthostatic intolerance. CMAJ
164: 372-376
[Abstract][Full Text]
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(2001). Age and gender differences in basal and isoprenaline protocols for head-up tilt table testing. Europace
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Graham, L. A., Kenny, R. A.
(2001). Clinical characteristics of patients with vasovagal reactions presenting as unexplained syncope. Europace
3: 141-146
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Mosqueda-Garcia, R., Furlan, R., MD, J. T., Fernandez-Violante, R.
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102: 2898-2906
[Full Text]
Fenton, A. M., Hammill, S. C., Rea, R. F., Low, P. A., Shen, W.-K.
(2000). Vasovagal Syncope. ANN INTERN MED
133: 714-725
[Abstract][Full Text]
Fitzpatrick, A. P., Zaidi, A.
(2000). Tilt methodology in reflex syncope: emerging evidence. J Am Coll Cardiol
36: 179-180
[Full Text]
Zaidi, A.M., Fitzpatrick, A.P.
(2000). Investigation of syncope: increasing the yield and reducing the cost. Eur Heart J
21: 877-880
Shen, W.-K., Low, P. A., Rea, R. F., Lohse, C. M., Hodge, D. O., Hammill, S. C.
(2000). Distinct hemodynamic profiles in patients with vasovagal syncope: a heterogeneous population. J Am Coll Cardiol
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[Abstract][Full Text]
Kenny, R A, O'Shea, D, Parry, S W
(2000). The Newcastle protocols for head-up tilt table testing in the diagnosis of vasovagal syncope, carotid sinus hypersensitivity, and related disorders. Heart
83: 564-569
[Full Text]
Zaidi, A, Benitez, D, Gaydecki, P A, Vohra, A, Fitzpatrick, A P
(2000). Haemodynamic effects of increasing angle of head up tilt. Heart
83: 181-184
[Abstract][Full Text]
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(1999). Tilt table testing in the diagnosis of unexplained syncope. QJM
92: 623-629
[Full Text]
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(1999). Inadequate sympathovagal balance in response to orthostatism in patients with unexplained syncope and a positive head up tilt test. Heart
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[Abstract][Full Text]
Oraii, S, Maleki, M, Minooii, M, Kafaii, P
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81: 603-605
[Abstract][Full Text]
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(1999). Utility of a single-stage isoproterenol tilt table test in adults: A randomized comparison with passive head-up tilt. J Am Coll Cardiol
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[Abstract][Full Text]
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[Abstract][Full Text]
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[Abstract]
Bartoletti, A., Gaggioli, G., Menozzi, C., Bottoni, N., Del Rosso, A., Mureddu, R., Musso, G., Foglia-Manzillo, G., Bonfigli, B., Brignole, M.
(1999). Head-up tilt testing potentiated with oral nitroglycerin; a randomized trial of the contribution of a drug-free phase and a nitroglycerin phase in the diagnosis of neurally mediated syncope. Europace
1: 183-186
[Abstract]
Hermosillo, A.G., Falcon, J.C., Marquez, M.F., Arteaga, D., Cardenas, M.
(1999). Positive head-up tilt table test in patients with the long QT syndrome. Europace
1: 213-217
[Abstract]
Furlan, R., Piazza, S., Dell'Orto, S., Barbic, F., Bianchi, A., Mainardi, L., Cerutti, S., Pagani, M., Malliani, A.
(1998). Cardiac Autonomic Patterns Preceding Occasional Vasovagal Reactions in Healthy Humans. Circulation
98: 1756-1761
[Abstract][Full Text]
Ward, C R, Gray, J C, Gilroy, J J, Kenny, R A
(1998). Midodrine: a role in the management of neurocardiogenic syncope. Heart
79: 45-49
[Abstract][Full Text]
Flammang, D., Church, T., Waynberger, M., Chassing, A., Antiel, M.
(1997). Can Adenosine 5'-Triphosphate Be Used to Select Treatment in Severe Vasovagal Syndrome?. Circulation
96: 1201-1208
[Abstract][Full Text]
Mallat, Z., Vicaut, E., Sangare, A., Verschueren, J., Fontaine, G., Frank, R.
(1997). Prediction of Head-Up Tilt Test Result by Analysis of Early Heart Rate Variations. Circulation
96: 581-584
[Abstract][Full Text]
Ligtenberg, G., Blankestijn, P. J., Oey, P. L., Wieneke, G. H., van Huffelen, A. C., Koomans, H. A.
(1997). Cold Stress Provokes Sympathoinhibitory Presyncope in Healthy Subjects and Hemodialysis Patients With Low Cardiac Output. Circulation
95: 2271-2276
[Abstract][Full Text]
Englund, A., Fredrikson, M., Rosenqvist, M.°r.
(1997). Head-up Tilt Test: A Nonspecific Method of Evaluating Patients With Bifascicular Block. Circulation
95: 951-954
[Abstract][Full Text]
Thomson, H. L., Wright, K., Frenneaux, M.
(1997). Baroreflex Sensitivity in Patients With Vasovagal Syncope. Circulation
95: 395-400
[Abstract][Full Text]
Epstein, A. E., Miles, W. M., Benditt, D. G., Camm, A. J., Darling, E. J., Friedman, P. L., Garson, A., Harvey, J. C., Kidwell, G. A., Klein, G. J., Levine, P. A., Marchlinski, F. E., Prystowsky, E. N., Wilkoff, B. L.
(1996). Personal and Public Safety Issues Related to Arrhythmias That May Affect Consciousness: Implications for Regulation and Physician Recommendations: A Medical/Scientific Statement From the American Heart Association and the North American Society of Pacing and Electrophysiology. Circulation
94: 1147-1166
[Full Text]
Thomson, H. L., Atherton, J. J., Khafagi, F. A., Frenneaux, M. P.
(1996). Failure of Reflex Venoconstriction During Exercise in Patients With Vasovagal Syncope. Circulation
93: 953-959
[Abstract][Full Text]
Sheldon, R., Rose, S., Flanagan, P., Koshman, M. L., Killam, S.
(1996). Risk Factors for Syncope Recurrence After a Positive Tilt-Table<$DOWNLINK> Test in Patients With Syncope. Circulation
93: 973-981
[Abstract][Full Text]
Poppas, A., Sawyer, R., Kinder, C., Vignon, P., Bednarz, J., Lee, B. K., Feldman, T., Glagov, S., Lang, R. M.
(1996). A 73-Year-Old Man With Hypertension and Syncope. Circulation
93: 380-386
[Full Text]
Kusumoto, F. M., Goldschlager, N.
(1996). Cardiac Pacing. NEJM
334: 89-99
[Full Text]
Thomson, H. L., Lele, S. S., Atherton, J. J., Wright, K. N., Stafford, W., Frenneaux, M. P.
(1995). Abnormal Forearm Vascular Responses During Dynamic Leg Exercise in Patients With Vasovagal Syncope. Circulation
92: 2204-2209
[Abstract][Full Text]
Bou-Holaigah, I., Rowe, P. C., Kan, J., Calkins, H.
(1995). The Relationship Between Neurally Mediated Hypotension and the Chronic Fatigue Syndrome. JAMA
274: 961-967
[Abstract]
Natale, A., Akhtar, M., Jazayeri, M., Dhala, A., Blanck, Z., Deshpande, S., Krebs, A., Sra, J. S.
(1995). Provocation of Hypotension During Head-Up Tilt Testing in Subjects With No History of Syncope or Presyncope. Circulation
92: 54-58
[Abstract][Full Text]
Tonnessen, G. E., Haft, J. I., Fulton, J., Rubenstein, D. G.
(1994). The Value of Tilt Table Testing With Isoproterenol in Determining Therapy in Adults With Syncope and Presyncope of Unexplained Origin. Arch Intern Med
154: 1613-1617
[Abstract]
Cooper, C. J., Ridker, P., Shea, J., Creager, M. A.
(1994). Familial Occurrence of Neurocardiogenic Syncope. NEJM
331: 205-205
[Full Text]
van Lieshout, J. J., Jellema, W. T., Wieling, W., Fitzpatrick, A. P., Papa, L. J., Sra, J. S.
(1993). Treatment of Neurocardiogenic Syncope. NEJM
329: 969-970
[Full Text]
Sra, J. S., Jazayeri, M. R., Avitall, B., Dhala, A., Deshpande, S., Blanck, Z., Akhtar, M.
(1993). Comparison of Cardiac Pacing with Drug Therapy in the Treatment of Neurocardiogenic (Vasovagal) Syncope with Bradycardia or Asystole. NEJM
328: 1085-1090
[Abstract][Full Text]
Kapoor, W. N.
(1992). Evaluation and Management of the Patient With Syncope. JAMA
268: 2553-2560
[Abstract]
Kapoor, W. N., Brant, N.
(1992). Evaluation of Syncope by Upright Tilt Testing with Isoproterenol: A Nonspecific Test. ANN INTERN MED
116: 358-363
[Abstract]
Grubb, B. P., Gerard, G., Roush, K., Temesy-Armos, P., Elliott, L., Hahn, H., Spann, C.
(1991). Differentiation of Convulsive Syncope and Epilepsy with Head-Up Tilt Testing. ANN INTERN MED
115: 871-876
[Abstract]
Nelson, S. D., Stanley, M., Love, C. J., Coyne, K. S., Schaal, S. F.
(1991). The Autonomic and Hemodynamic Effects of Oral Theophylline in Patients With Vasodepressor Syncope. Arch Intern Med
151: 2425-2429
[Abstract]
Sra, J. S., Anderson, A. J., Sheikh, S. H., Avitall, B., Tchou, P. J., Troup, P. J., Gilbert, C. J., Akhtar, M., Jazayeri, M. R.
(1991). Unexplained Syncope Evaluated by Electrophysiologic Studies and Head-up Tilt Testing. ANN INTERN MED
114: 1013-1019
[Abstract]
Manolis, A. S., Linzer, M., Salem, D., Estes, N. A. M. III
(1990). Syncope: Current Diagnostic Evaluation and Management. ANN INTERN MED
112: 850-863
[Abstract]
(1989). A USEFUL NEW TEST FOR DIAGNOSING VASOVAGAL SYNCOPE. JWatch General
1989: 4-4
[Full Text]
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