Skip to main content
PMC home page
Heart logoLink to Heart
. 2000 Nov;84(5):509–514. doi: 10.1136/heart.84.5.509

The normal response to prolonged passive head up tilt testing

M Petersen 1, T Williams 1, C Gordon 1, R Chamberlain-Webbe 1, R Sutton 1
PMCID: PMC1729464  PMID: 11040011

Abstract

OBJECTIVE—To define the responses to head up tilt in a large group of normal adult subjects using the most widely employed protocol for tilt testing.
METHODS—127 normal subjects aged 19-88 years (mean (SD), 49 (20) years) without a previous history of syncope underwent tilt testing at 60° for 45 minutes or until syncope intervened. Blood pressure monitoring was performed with digital photoplethysmography, providing continuous, non-invasive, beat to beat heart rate and pressure measurements.
RESULTS—13% of subjects developed vasovagal syncope after a mean (SD) tilt time of 31.7 (12.4) minutes (range 8.5-44.9 minutes). Severe cardioinhibition during syncope was observed less often than is reported in patients investigated for syncope. There were no differences in the age or sex distributions of subjects with positive or negative outcomes, or in the proportions with cardioinhibitory and vasodepressor vasovagal syncope compared with previously reported patient populations. Subjects with negative outcomes showed age related differences in heart rate and blood pressure behaviour throughout tilt.
CONCLUSIONS—False positive results with tilting appear to be common. This has important implications for the use of diagnostic tilt testing. The magnitude of the heart rate and blood pressure changes observed during negative tilts largely invalidates previously suggested criteria for abnormal non-syncopal outcomes.


Keywords: syncope; head up tilt; postural hypotension

Full Text

The Full Text of this article is available as a PDF (150.8 KB).

Figure 1  .

Figure 1  

Open in a new tab

Change in systolic pressure (mm Hg) during tilt with respect to resting supine pre-tilt systolic pressure.

Figure 2  .

Figure 2  

Open in a new tab

Change in diastolic pressure (mm Hg) during tilt with respect to resting supine pre-tilt diastolic pressure.

Figure 3  .

Figure 3  

Open in a new tab

Change in heart rate (beats/min) during tilt with respect to resting supine pre-tilt heart rate.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Abi-Samra F., Maloney J. D., Fouad-Tarazi F. M., Castle L. W. The usefulness of head-up tilt testing and hemodynamic investigations in the workup of syncope of unknown origin. Pacing Clin Electrophysiol. 1988 Aug;11(8):1202–1214. doi: 10.1111/j.1540-8159.1988.tb03973.x. [DOI] [PubMed] [Google Scholar]
  2. BEACONSFIELD P., GINSBURG J. The effect of body posture on the hand blood flow. J Physiol. 1955 Nov 28;130(2):467–473. doi: 10.1113/jphysiol.1955.sp005420. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Benditt D. G., Remole S., Bailin S., Dunnigan A., Asso A., Milstein S. Tilt table testing for evaluation of neurally-mediated (cardioneurogenic) syncope: rationale and proposed protocols. Pacing Clin Electrophysiol. 1991 Oct;14(10):1528–1537. doi: 10.1111/j.1540-8159.1991.tb04074.x. [DOI] [PubMed] [Google Scholar]
  4. Boehmer R. D. Continuous, real-time, noninvasive monitor of blood pressure: Penaz methodology applied to the finger. J Clin Monit. 1987 Oct;3(4):282–287. doi: 10.1007/BF03337384. [DOI] [PubMed] [Google Scholar]
  5. Borst C., Wieling W., van Brederode J. F., Hond A., de Rijk L. G., Dunning A. J. Mechanisms of initial heart rate response to postural change. Am J Physiol. 1982 Nov;243(5):H676–H681. doi: 10.1152/ajpheart.1982.243.5.H676. [DOI] [PubMed] [Google Scholar]
  6. Brignole M., Menozzi C., Gianfranchi L., Oddone D., Lolli G., Bertulla A. Carotid sinus massage, eyeball compression, and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J. 1991 Dec;122(6):1644–1651. doi: 10.1016/0002-8703(91)90282-m. [DOI] [PubMed] [Google Scholar]
  7. Brignole M., Menozzi C., Gianfranchi L., Oddone D., Lolli G., Bertulla A. Neurally mediated syncope detected by carotid sinus massage and head-up tilt test in sick sinus syndrome. Am J Cardiol. 1991 Oct 15;68(10):1032–1036. doi: 10.1016/0002-9149(91)90491-3. [DOI] [PubMed] [Google Scholar]
  8. Cheng T. O. Need for standardization of tilt-table test in evaluation of syncope. Am J Cardiol. 1992 Dec 15;70(20):1639–1639. doi: 10.1016/0002-9149(92)90483-f. [DOI] [PubMed] [Google Scholar]
  9. Dambrink J. H., Wieling W. Circulatory response to postural change in healthy male subjects in relation to age. Clin Sci (Lond) 1987 Mar;72(3):335–341. doi: 10.1042/cs0720335. [DOI] [PubMed] [Google Scholar]
  10. Davies R., Slater J. D., Forsling M. L., Payne N. The response of arginine vasopressin and plasma renin to postural change in normal man, with observations on syncope. Clin Sci Mol Med. 1976 Sep;51(3):267–274. doi: 10.1042/cs0510267. [DOI] [PubMed] [Google Scholar]
  11. Epstein R. H., Bartkowski R. R., Huffnagle S. Continuous noninvasive finger blood pressure during controlled hypotension. A comparison with intraarterial pressure. Anesthesiology. 1991 Nov;75(5):796–803. doi: 10.1097/00000542-199111000-00011. [DOI] [PubMed] [Google Scholar]
  12. Farquhar I. K. Continuous direct and indirect blood pressure measurement (Finapres) in the critically ill. Anaesthesia. 1991 Dec;46(12):1050–1055. doi: 10.1111/j.1365-2044.1991.tb09922.x. [DOI] [PubMed] [Google Scholar]
  13. Fitzpatrick A. P., Theodorakis G., Vardas P., Sutton R. Methodology of head-up tilt testing in patients with unexplained syncope. J Am Coll Cardiol. 1991 Jan;17(1):125–130. doi: 10.1016/0735-1097(91)90714-k. [DOI] [PubMed] [Google Scholar]
  14. Grubb B. P., Temesy-Armos P., Hahn H., Elliott L. Utility of upright tilt-table testing in the evaluation and management of syncope of unknown origin. Am J Med. 1991 Jan;90(1):6–10. doi: 10.1016/0002-9343(91)90499-n. [DOI] [PubMed] [Google Scholar]
  15. Hackel A., Linzer M., Anderson N., Williams R. Cardiovascular and catecholamine responses to head-up tilt in the diagnosis of recurrent unexplained syncope in elderly patients. J Am Geriatr Soc. 1991 Jul;39(7):663–669. doi: 10.1111/j.1532-5415.1991.tb03619.x. [DOI] [PubMed] [Google Scholar]
  16. Hainsworth R., Al-Shamma Y. M. Cardiovascular responses to upright tilting in healthy subjects. Clin Sci (Lond) 1988 Jan;74(1):17–22. doi: 10.1042/cs0740017. [DOI] [PubMed] [Google Scholar]
  17. Hoeldtke R. D., Davis K. M. The orthostatic tachycardia syndrome: evaluation of autonomic function and treatment with octreotide and ergot alkaloids. J Clin Endocrinol Metab. 1991 Jul;73(1):132–139. doi: 10.1210/jcem-73-1-132. [DOI] [PubMed] [Google Scholar]
  18. Imholz B. P., Settels J. J., van der Meiracker A. H., Wesseling K. H., Wieling W. Non-invasive continuous finger blood pressure measurement during orthostatic stress compared to intra-arterial pressure. Cardiovasc Res. 1990 Mar;24(3):214–221. doi: 10.1093/cvr/24.3.214. [DOI] [PubMed] [Google Scholar]
  19. Jaeger F. J., Maloney J. D., Castle L. W., Fouad-Tarazi F. M. Is absolute hypovolemia a risk factor for vasovagal response to head-up tilt? Pacing Clin Electrophysiol. 1993 Apr;16(4 Pt 1):743–750. doi: 10.1111/j.1540-8159.1993.tb01654.x. [DOI] [PubMed] [Google Scholar]
  20. KROEKER E. J., WOOD E. H. Comparison of simultaneously recorded central and peripheral arterial pressure pulses during rest, exercise and tilted position in man. Circ Res. 1955 Nov;3(6):623–632. doi: 10.1161/01.res.3.6.623. [DOI] [PubMed] [Google Scholar]
  21. Kalbfleisch J. H., Reinke J. A., Porth C. J., Ebert T. J., Smith J. J. Effect of age on circulatory response to postural and valsalva tests (39884). Proc Soc Exp Biol Med. 1977 Oct;156(1):100–103. doi: 10.3181/00379727-156-39884. [DOI] [PubMed] [Google Scholar]
  22. Kapoor W. N., Brant N. Evaluation of syncope by upright tilt testing with isoproterenol. A nonspecific test. Ann Intern Med. 1992 Mar 1;116(5):358–363. doi: 10.7326/0003-4819-116-5-358. [DOI] [PubMed] [Google Scholar]
  23. Kapoor W. N., Smith M. A., Miller N. L. Upright tilt testing in evaluating syncope: a comprehensive literature review. Am J Med. 1994 Jul;97(1):78–88. doi: 10.1016/0002-9343(94)90051-5. [DOI] [PubMed] [Google Scholar]
  24. Kaufmann H., Oribe E., Oliver J. A. Plasma endothelin during upright tilt: relevance for orthostatic hypotension? Lancet. 1991 Dec 21;338(8782-8783):1542–1545. doi: 10.1016/0140-6736(91)92370-h. [DOI] [PubMed] [Google Scholar]
  25. Kenny R. A., Ingram A., Bayliss J., Sutton R. Head-up tilt: a useful test for investigating unexplained syncope. Lancet. 1986 Jun 14;1(8494):1352–1355. doi: 10.1016/s0140-6736(86)91665-x. [DOI] [PubMed] [Google Scholar]
  26. Kermode J. L., Davis N. J., Thompson W. R. Comparison of the Finapres blood pressure monitor with intra-arterial manometry during induction of anaesthesia. Anaesth Intensive Care. 1989 Nov;17(4):470–475. doi: 10.1177/0310057X8901700413. [DOI] [PubMed] [Google Scholar]
  27. Kligfield P. Tilt table for the investigation of syncope: there is nothing simple about fainting. J Am Coll Cardiol. 1991 Jan;17(1):131–132. doi: 10.1016/0735-1097(91)90715-l. [DOI] [PubMed] [Google Scholar]
  28. Leor J., Rotstein Z., Vered Z., Kaplinsky E., Truman S., Eldar M. Absence of tachycardia during tilt test predicts failure of beta-blocker therapy in patients with neurocardiogenic syncope. Am Heart J. 1994 Jun;127(6):1539–1543. doi: 10.1016/0002-8703(94)90383-2. [DOI] [PubMed] [Google Scholar]
  29. Lipsitz L. A., Mietus J., Moody G. B., Goldberger A. L. Spectral characteristics of heart rate variability before and during postural tilt. Relations to aging and risk of syncope. Circulation. 1990 Jun;81(6):1803–1810. doi: 10.1161/01.cir.81.6.1803. [DOI] [PubMed] [Google Scholar]
  30. Molhoek G. P., Wesseling K. H., Settels J. J., van Vollenhoven E., Weeda H. W., de Wit B., Arntzenius A. C. Evaluation of the Penàz servo-plethysmo-manometer for the continuous, non-invasive measurement of finger blood pressure. Basic Res Cardiol. 1984 Sep-Oct;79(5):598–609. doi: 10.1007/BF01910489. [DOI] [PubMed] [Google Scholar]
  31. Murray R. H., Bowers J. A., Goltra E. R. Comparison of footboard and saddle supports for orthostatic tests on a tilt table. J Appl Physiol. 1966 Jul;21(4):1409–1411. doi: 10.1152/jappl.1966.21.4.1409. [DOI] [PubMed] [Google Scholar]
  32. Natale A., Akhtar M., Jazayeri M., Dhala A., Blanck Z., Deshpande S., Krebs A., Sra J. S. Provocation of hypotension during head-up tilt testing in subjects with no history of syncope or presyncope. Circulation. 1995 Jul 1;92(1):54–58. doi: 10.1161/01.cir.92.1.54. [DOI] [PubMed] [Google Scholar]
  33. Oh J. J., Kim C. H. Gastroparesis after a presumed viral illness: clinical and laboratory features and natural history. Mayo Clin Proc. 1990 May;65(5):636–642. doi: 10.1016/s0025-6196(12)65125-8. [DOI] [PubMed] [Google Scholar]
  34. Petersen M. E., Williams T. R., Sutton R. Psychogenic syncope diagnosed by prolonged head-up tilt testing. QJM. 1995 Mar;88(3):209–213. [PubMed] [Google Scholar]
  35. Raviele A., Gasparini G., Di Pede F., Delise P., Bonso A., Piccolo E. Usefulness of head-up tilt test in evaluating patients with syncope of unknown origin and negative electrophysiologic study. Am J Cardiol. 1990 Jun 1;65(20):1322–1327. doi: 10.1016/0002-9149(90)91321-v. [DOI] [PubMed] [Google Scholar]
  36. Rowell L. B., Brengelmann G. L., Blackmon J. R., Bruce R. A., Murray J. A. Disparities between aortic and peripheral pulse pressures induced by upright exercise and vasomotor changes in man. Circulation. 1968 Jun;37(6):954–964. doi: 10.1161/01.cir.37.6.954. [DOI] [PubMed] [Google Scholar]
  37. Sander-Jensen K., Secher N. H., Astrup A., Christensen N. J., Giese J., Schwartz T. W., Warberg J., Bie P. Hypotension induced by passive head-up tilt: endocrine and circulatory mechanisms. Am J Physiol. 1986 Oct;251(4 Pt 2):R742–R748. doi: 10.1152/ajpregu.1986.251.4.R742. [DOI] [PubMed] [Google Scholar]
  38. Shalev Y., Gal R., Tchou P. J., Anderson A. J., Avitall B., Akhtar M., Jazayeri M. R. Echocardiographic demonstration of decreased left ventricular dimensions and vigorous myocardial contraction during syncope induced by head-up tilt. J Am Coll Cardiol. 1991 Sep;18(3):746–751. doi: 10.1016/0735-1097(91)90798-e. [DOI] [PubMed] [Google Scholar]
  39. Shvartz E., Meyerstein N. Tilt tolerance of young men and young women. Aerosp Med. 1970 Mar;41(3):253–255. [PubMed] [Google Scholar]
  40. Shvartz E. Reliability of quantitative tilt table data. Aerosp Med. 1968 Oct;39(10):1094–1097. [PubMed] [Google Scholar]
  41. Stevens P. M. Cardiovascular dynamics during orthostasis and the influence of intravascular instrumentation. Am J Cardiol. 1966 Feb;17(2):211–218. doi: 10.1016/0002-9149(66)90354-7. [DOI] [PubMed] [Google Scholar]
  42. Strasberg B., Rechavia E., Sagie A., Kusniec J., Mager A., Sclarovsky S., Agmon J. The head-up tilt table test in patients with syncope of unknown origin. Am Heart J. 1989 Nov;118(5 Pt 1):923–927. doi: 10.1016/0002-8703(89)90225-1. [DOI] [PubMed] [Google Scholar]
  43. Wahbha M. M., Morley C. A., al-Shamma Y. M., Hainsworth R. Cardiovascular reflex responses in patients with unexplained syncope. Clin Sci (Lond) 1989 Nov;77(5):547–553. doi: 10.1042/cs0770547. [DOI] [PubMed] [Google Scholar]

Articles from Heart are provided here courtesy of BMJ Publishing Group

RESOURCES