Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness

An expert committee was formed to reach consensus on the use of tilt table testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous events. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to the performance of (1) additional provocation tests, such as the active standing test, carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; and (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.

Cardiovascular autonomic testing in the work-up of cerebellar ataxia: insight from an observational single center study

Background Cerebellar ataxias are a heterogeneous group of disorders of both genetic and non-genetic origin. In sporadic cases, two entities are recognized: multiple system atrophy of cerebellar type (MSA-C) and SAOA (sporadic adult-onset ataxia). The presence of severe cardiovascular autonomic failure reliably distinguishes MSA-C from other ataxias, but it may appear only late in the disease course. Objective To evaluate the diagnostic yield of cardiovascular autonomic function tests in the work-up of cerebellar ataxia. Methods We applied a cardiovascular autonomic tests battery in consecutive patients with neurodegenerative cerebellar ataxia and matched healthy controls. We recorded the presence of both orthostatic hypotension (OH) and blood pressure falls non-fulfilling the criteria of OH (non-OH BP). Sporadic cases were followed-up for an eventual conversion to MSA-C. Results Forty-two patients were recruited, 19 of whom with sporadic disease (2 probable MSA-C, 6 possible MSA-C, 11 SAOA). Sporadic and hereditary cases showed no difference concerning ataxia severity at baseline. At head-up tilt, non-OH BP falls were detected in nine patients, but not in controls. This finding was significantly more frequent in sporadic cases (p = 0.006) and was detected in five out of seven patients that during follow-up converted to possible/probable MSA-C. Findings at standing test were normal in four out of nine cases with non-OH BP falls at head-up tilt. Conclusions A complete cardiovascular autonomic battery with head-up tilt can detect early signs of BP dysregulation which may be missed at bed-side tests, thus warranting its application in the first line work-up of cerebellar ataxias.

Relationship of hypoglycemia and glucose variability with autonomic dysfunction in children and adolescents with type 1 diabetes

Aim. Glucose variability (GV) and hypoglycaemia frequency and duration, depending on cardiovascular autonomic dysfunction, in children and adolescents with type 1 diabetes mellitus (T1DM) were evaluated. Materials and methods. One hundred and thirty T1DM patients, aged 6?18 years, were included in this study. The study included 3 tests:. continuous glucose monitoring (CGM) with GV evaluation, frequency and duration of hypoglycaemia;24-h ECG monitoring with automatic calculation of QTc interval and heart rate variability (HRV) parameters;cardiovascular autonomic tests.Results. The estimated prevalence of cardiovascular autonomic neuropathy (CAN) was 19.2%. CAN positive (CAN+) patients had lower values from cardiovascular autonomic tests and HRV and longer QTc intervals compared with CAN negative (CAN-) patients (p

Cardiovascular autonomic tests in diabetic patients with gastroparesis

The aim of this report was to study the cardiovascular autonomic tests in the evaluation of diabetic patients with gastroparesis. Forty diabetic subjects were divided into two groups: one group with gastroparesis (GP, n=20) and another group paired by age and duration of diabetes without any complaint of autonomic neuropathy (DC, n=20) . They were evaluated clinically and submitted to a battery of five cardiovascular autonomic tests. The presence and severity of autonomic neuropathy were defined according to the number of normal cardiovascular tests. Each test had a score: zero ( normal ), one ( borderline ) and two ( abnormal ). The GP group showed a higher abnormal total score in the cardiovascular autonomic test than the group without any complaint (6.6 ± 3.0 vs. 2.7 ± 1.4, p <0.01). These data suggest that diabetic with gastroparesis presents more abnormal cardiovascular autonomic tests than diabetic without autonomic neuropathy and these tests should be included in the evaluation of diabetic patients with gastroparesis.