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HUTT Head-up Tilt Test

PRESENTED BY

DR. DEEPAK JAIN


TEAM CARDIOLOGY

Defination
A Head-up tilt table test is a medical procedure often used to diagnose dysautonomia or syncope(Vasovagal syncope). Patients with symptoms of dizziness or lightheadedness, with or without a loss of consciousness (fainting), suspected to be associated with a drop in blood pressure or positional bradycardia are good candidates for this test.

Scope of problem of syncope


Loss of consciousness has been a medical emergency. ~3% of ER visits and from 1-6% of general hospital

admissions in USA At least 3% of population can be expected to experience a syncopal episode during an approximately 25 years period of observation. Recurrence in ~30% - needs assessment. Single event in those with high risk occupation or avocations(e.g., pilots, commercial drivers, surgeons, window washers) or accompanying certain high profile activities (e.g., competitive athletes), may warrant assesssment.

History
In 1628, first clues that may lie behind loss of consciousness

emerged, when William Harvey described a circulatory response (vasovagal reaction) during phlebotomy First use of tilt table reported in 1800s. Term vasovagal syncope introduced by Gowers in 1907. In 1918, Cotton & Lewis described clinical characteristics of vasovagal syncope. Lewis described it as combination of bradycardia, hypotension and syncope in 1932. Weissler et al. used the tilt table with a 20% abnormal result in 1957. Kenny et al. published first research paper on this sublect in 1986 where he used tilt table at 40 for 60 mins and achieved a positive result in 60% patients, while only 10% controls developed syncope. Head up tilt test was introduced in clinical practice in 1986.

Benefits of HUTT
Means to compare provoked syncope with

episodes of spontaneous syncope.

Satisfaction to patient that doctor has


witnessed the symptomconfidence on treatment.
Helps patient recognize warning symptoms. Can be used to assess the response to treatment.

Controversies
??Clinical vasovagal syncope =induced syncope??

Protocol indicated for all patients??


Standard protocol?? Abnormal response??

Any other use for the tilt table??


Expected complications during the procedure??

Similar premonitory symptoms and signs, the

sequence of change in the blood pressure and heart rate, and similarity of plasma catecholamines before and after spontaneous and induced syncope lead credence to the conclusion that in the case of vasovagal syncope, induced and spontaneous episodes have a good correlation.

ACC recommendations for HUTT-1/3


Tilt table testing is warranted Recurrent syncope or single syncopal episode in a high risk patient, whether or not the medical history is suggestive of neurally mediated (vasovagal) origin, and 1. No evidence of structural cardiovascular disease or 2. Structural cardiovascular disease is present, but other causes of syncope have been excluded by appropriate testing Further evaluation of patients in whom an apparent cause has been established (e.g., asystole, atrioventricular block), but in whom demonstration of susceptibility to neurally mediated syncope would affect treatment plans c Part of the evaluation of exercise-induced or exerciseassociated syncope

ACC recommendations for HUTT-2/3


Reasonable differences of opinion exist regarding utility of tilt table testing Differentiating convulsive syncope from seizures Evaluating patients (especially the elderly) with recurrent unexplained falls Assessing recurrent dizziness or presyncope Evaluating unexplained syncope in the setting of peripheral neuropathies or dysautonomias Follow-up evaluation to assess therapy of neurally mediated syncope

ACC recommendations for HUTT-3/3


Tilt table testing not warranted Single syncopal episode, without injury and not in a high risk setting with clear-cut vasovagal clinical features Syncope in which an alternative specific cause has been established and in which additional demonstration of a neurally mediated susceptibility would not alter treatment plans

Potential emerging indications


Recurrent idiopathic vertigo

Recurrent transient ischemic attacks


Chronic fatigue syndrome Sudden infant death syndrome (SIDS) Seizure of unknown cause In treatment of pure vasovagal syncope To assess utility of therapies-pharmacological and

device oriented. Screening for patients with cerebral hemodynamics insufficiency in carotid occlusive disease.

Tilt-Table Testing Technique 1/2


Laboratory
Patient

Recordings

Table Tilt angle

-Quiet, dim lighting, comfortable temperature -2045-min supine equilibration period -Fasting overnight or for several hours before procedure -Parenteral fluid replacement -Follow-up studies should be at similar times of day -Minimum of three ECG leads continuously recorded -Beat-to-beat blood pressure recordings using the least intrusive means -Foot-board support -Smooth, rapid transitions (up and down) -60 to 80 acceptable -70 becoming most common

Tilt-Table Testing Technique 2/2


Tilt duration Pharmacologic

provocation
Supervision

Pediatrics

-Initial drug-free tilt 3045 min depends on agent -Isoproterenol (infusion preferred) -Nitroglycerin -Edrophonium -Nurse or laboratory technician experienced in tilt table technique and cardiovascular laboratory procedures -Physician in attendance or immediately available -Presents special problems -Tilt duration less certain -Blood pressure recording by sphygmomanometer is common

Different protocols
Basal or Westminster protocol Angle of 60 45 mins Without IV drugs 75% sensitivity, 93% specificity Isoprenalin protocol Angle of 70-80 Drug-Isoprenalin Initial 10 mins drug free then 1-5 g/min of Isoprenalin 87% sensitivity(60-87%) 85% specificity(85-90%)

Different protocols
Nitroglycerin protocol(Italian Protocol)

60 angle 20 mins without drugs and then 15 mins after 400g of sublingual nitroglucerin. Sensitivity 62% Specificity 92%

Other protocols Using edrophonium-10 mg intravenous bolus Using clomipramine-5 mg IV


Tests without drugs-higher specificity Tests with drugs-higher sensitivity

A STANDARD TILT TEST PROTOCOL


Foot

board support tilt table (preferably motorized and electronically controlled). Supine pre-tilt phase of >=5min. When no venous cannulation is performed, and >=20min. When cannulation is undertaken. Tilt angle of approximately 700. Passive phase of 20 40 min. duration. Intravenous isoproterenol or sublingual nitroglycerine for drug provocation if passive phase has been negative. The drug challenge phase duration is 20 mins.

Isoproterenol incremental infusion rate of 1

3mg/min. in order to increase average heart rate by about 20 25% over baseline administered without returning the patient to the supine position. Nitroglycerin fixed dose of 400g NTG spray sublingually administered in the HUP. Endpoint is defined as induction of syncope or completion of the planned duration of tilt including the drug provocation. The test is considered positive if syncope occurs, especially if it reproduces patients symptoms.

Results and interpretation


Negative

no variation or minor fluctuations of BP and HR Positive LOC with BP and/or HR changes Other responces

Neurocardiogenic symptoms with Acute hypotension with/without bradycardia Autonomic dysfunction due to progressive and parallel fall of BP Orthostatic postural tachycardia with
Increased HR 30 / min in first 10 mins of tilting HR120 beats /min in first 10 mins of tilting Increased HR 30 beats /min when isoprenalin is infused /1 g/min.

Cerebral symptoms Psychogenic symptoms only

Classification of positive response


Type I(Mixed) HR falls at time of syncope but ventricular rate does not fall to <40 or falls to <40 for less then 10 secs with/without asytole of <3 secs. BP falls before the HR falls a. HR falls to ventricular rate <40 for >10 secs but systole of >3 secs does not occur. BP falls before HR falls. b. Aystole of >3 secs. BP falls with or before HR falls. HR does not fall by more than 10% of its peak at the time of syncope. BP falls to >50mmHg or 30 mmHg if symptomatic.

Type II(Cardio-Inhibitory)

Type III(Vasodepressor)

Termination of test
For appropriate classification test should be

terminated precisely at the moment when consciousnesses and postural tone is lost. Premature termination will result in underestimation, while delayed termination will result in overestimation of cardio-inhibitory response and exposure to the consequences of prolonged unconsciousness.

Complications
Prolonged asystole-complication/end point of the test

Palpitation due to isoprenalin


Headache due to nitrates Life threatening ventricular arrhythmias with use of

isoprenalin in patients with underlying IHD AF Tachycardia(44%), nausea(35%), chest pain(2.7%) and arrhythmias(6%) have lead to reduction of isoprenalin dose in 33% and discontinuation in 4.2%.

CONCLUSION
HUTT is the only diagnostic tool for the evaluation

of unexplained syncope. It is not recommended for the assessment of treatment efficacy in vasovagal syndrome. There is no evidence that HUT can be used to justify the placement of a cardiac pacemaker no matter the duration of a HUT induced pause.

The choice of beta blockers as a treatment strategy

rely on other factors (e.g. young age, exertion related symptoms). Patients with significant structural heart disease or other findings suggesting predilections to arrhythmia (e.g. long QT internal, pre-excitation syndrome, prior myocardial infarction, CMP) should be thoroughly evaluated and excluded prior to HUTT recommendations.