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Autonomic uprising: the tilt table test in autonomic medicine

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Abstract

This perspective piece on head-up tilt table testing is part of a series on autonomic function testing. The tilt table can be a useful diagnostic test, but methodologies vary, and the results are sometimes misinterpreted. The intent here is not to review comprehensively the utility of various tilt table testing protocols but to convey a number of general points that may give perspective and have practical clinical value, based on an understanding of autonomic physiology and our long clinical and research experience in the evaluation of autonomic disorders. The goals of tilt table testing are to assess orthostatic hypotension (OH), chronic orthostatic intolerance (COI), and unexplained syncope. The testing is useful for distinguishing neurogenic from non-neurogenic OH, identifying failure of the sympathetic noradrenergic system in autonomic neuropathies and ganglionopathies, and assessing baroreflex-sympathoneural function in α-synucleinopathies. For COI, the testing can provide objective data related to the patient’s symptoms, diagnose postural tachycardia syndrome (POTS), and distinguish POTS from other causes of tachycardia. Provocative tilt table testing can help understand bases for recurrent transient loss of consciousness in patients with syncope, distinguish neurally mediated syncope from psychogenic pseudosyncope, and separate syncope-related convulsion from epileptic seizures. For each of these purposes, the goals, formats, endpoints, and clinical utility are different. As for any autonomic test, tilt table findings must be interpreted in the context of the patient’s clinical presentation.

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Abbreviations

ANS:

Autonomic nervous system

BP:

Blood pressure

COI:

Chronic orthostatic intolerance

EPI:

Epinephrine

FVR:

Forearm vascular resistance

HR:

Heart rate

HUT:

Head-up tilt

NE:

Norepinephrine

NET:

Cell membrane norepinephrine transporter

NMH:

Neurally mediated hypotension

nOH:

Neurogenic orthostatic hypotension

OH:

Orthostatic hypotension

POTS:

Postural tachycardia syndrome

SNS:

Sympathetic noradrenergic system

SV:

Cardiac stroke volume

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Authors and Affiliations

  1. Department of Neurology, Mayo Clinic, Jacksonville, FL, 32224, USA

    William P. Cheshire Jr.

  2. Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological, Disorders and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA

    David S. Goldstein

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Cheshire, W.P., Goldstein, D.S. Autonomic uprising: the tilt table test in autonomic medicine. Clin Auton Res 29, 215–230 (2019). https://doi.org/10.1007/s10286-019-00598-9

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