Is the Type of Cardiovascular Response During Tilt Table Testing Useful for the Choice of the Treatment? The New VASIS Classification

  • M. Brignole
  • C. Menozzi
  • A. Del Rosso
  • S. Costa
  • G. Gaggioli
  • A. Solano
  • N. Bottoni
  • P. Bartoli
  • R. Sutton
Conference paper


Worldwide experience of more than 10 years of tilt testing has shown that, while it has dramatically reduced the number of patients whose syncope cannot be explained, the population of patients who show a positive response to the test is greatly heterogeneous, raising the possibility that different syndromes can be diagnosed by tilt testing. Many drugs as well as cardiac pacing have been proposed for patients with tilt-induced syncope; however, a consensus on management has not been achieved due to the unsatisfactory results of trials of therapy which have been undertaken. The classification of the Vasovagal Syncope International Study (VASIS) was developed in 1992 in order to facilitate the understanding of the different types of vasovagal reactions that were observed during tilt-induced syncope [1]. This has been recently extended to tilt testing with pharmacological challenge [2, 3]. Like the other current classifications of the positive responses to tilt testing, the VASIS classification is based on the different behaviour of the blood pressure and heart rate observed when the vasovagal reaction and symptoms occur. To date, the cardiovascular patterns preceding the development of the vasovagal reaction have received little study. We believe that the pattern of blood pressure response to tilt may provide more strict diagnostic information and that a more detailed although still arbitrary classification may form the basis of a number of future drug and pacemaker trials and may help us toward a better understanding of the different mechanisms of tilt-induced syncope. We, therefore, propose that the following classification should be used as a complementary classification in addition to the VASIS classification. Moreover, we have tried to correlate this classification with some simple clinical variables.


Chronic Fatigue Syndrome Carotid Sinus Orthostatic Intolerance Vasovagal Syncope Tilt Table Test 


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  1. 1.
    Sutton R, Petersen M, Brignole M, Raviele A, Menozzi C, Giani P (1992) Proposed classification for tilt induced vasovagal syncope. Eur J Cardiac Pacing Electrophysiol 2:180–183Google Scholar
  2. 2.
    Del Rosso A, Bartoli P, Bartoletti A, Brandinelli-Geri A, Bonechi F, Maioli M, Mazza F, Michelucci A, Russo L, Salvetti E, Sansoni M, Zipoli A, Fierro A, Ieri A (1998) Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope. Am Heart J 135:564–570PubMedCrossRefGoogle Scholar
  3. 3.
    Kurbaan AS, Fran’zen AC, Williams T, Wasan BS, Kaddoura S, Sutton R (1998) Vasovagal collapse patterns after the use of glyceryl trinitrate during tilt testing. PACE 21:794 (abstr)Google Scholar
  4. 4.
    Brignole M, Menozzi C, Gianfranchi L, Oddone D, Lolli G, Bertulla A (1991) Carotid sinus massage, eye-ball compression test and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J 122:1644–1651PubMedCrossRefGoogle Scholar
  5. 5.
    Brignole M, Menozzi C, Bottoni N, Gianfranchi L, Lolli G, Oddone D, Gaggioli G (1995) Mechanisms of syncope caused by transient bradycardia and the diagnostic value of electrophysiologic testing and cardiovascular reflexivity maneuvers. Am J Cardiol 76:273–278PubMedCrossRefGoogle Scholar
  6. 6.
    Raviele A, Menozzi C, Brignole M, Gasparini G, Alboni P, Musso G, Lolli G, Oddone D, Dinelli M, Mureddu R (1995) Value of head-up tilt testing potentiated with sublingual nitroglycerin to assess the origin of unexplained syncope. Am J Cardiol 76:267–272PubMedCrossRefGoogle Scholar
  7. 7.
    Friedman DB, Jensen FB, Matzen S, Secher NH (1990) Non-invasive blood pressure monitoring during head-up tilt test using the Penaz principle. Acta Anestesiol Scand 34:519–522CrossRefGoogle Scholar
  8. 8.
    Petersen MEV, Williams TR, Sutton R (1995) A comparison of non-invasive continuous finger blood pressure measurements (Finapres) with intra-arterial pressure during prolonged head-up tilt. Eur Heart J 16:1647–1654Google Scholar
  9. 9.
    Grubb B, Samoil D (1996) Neurocardiogenic syncope. In: Kenny RA (ed) Syncope in the older patient. Chapman & Hall, pp 91–106Google Scholar
  10. 10.
    Schutzman J, Jaeger F, Maloney J, Fouad-Tarazi F (1994) Head-up tilt and hemodynamic changes during orthostatic hypotension in patients with supine hypertension. J Am Coll Cardiol 24:454–461PubMedCrossRefGoogle Scholar
  11. 11.
    Betkoski A, Patei C, Halperin A, Jaeger F, Goren H, Fouad-Tarazi F (1995) Reporting on the results of tilt patterns of response offer more information than changes at end-point. Circulation 92:I–203 (abstr)Google Scholar
  12. 12.
    Morillo C, Eckberg D, Ellenbogen K, Beightol L, Hoang J, Tahvanainen K, Kuusela T, Diedrich A (1997) Vagal and sympathetic mechanisms in patients with orthostatic vasovagal syncope. Circulation 96:2509–2513PubMedCrossRefGoogle Scholar
  13. 13.
    Novak V, Novak P, Kus T, Nadeau R (1995) Slow cardiovascular rhythms in tilt and syncope. J Clin Neurophysiol 12:64–71PubMedGoogle Scholar
  14. 14.
    Glick G, Yu PN (1963) Hemodynamic changes during spontaneous vasovagal reactions. Am J Med 34:42–51PubMedCrossRefGoogle Scholar
  15. 15.
    Gaggioli G, Bottoni N, Mureddu R, Foglia-Manzillo G, Mascioli G, Bartoli P, Musso G, Menozzi C, MD, Brignole M (1997) Effects of chronic vasodilator therapy to enhance susceptibility to vasovagal syncope during upright tilt testing. Am J Cardiol 80:1092–1094PubMedCrossRefGoogle Scholar
  16. 16.
    Narkiewicz K, Somers V (1998) Chronic orthostatic intolerance. Part of a spectrum of dysfunction in orthostatic cardiovascular homeostasis? Circulation 98:2105–2107PubMedCrossRefGoogle Scholar
  17. 17.
    Furlan R, Jacob G, Snell M, Robertson D, Porta A, Harris P, Mosqueda-Garcia R (1998) Chronic orthostatic intolerance. A disorder with discordant cardiac and vascular sypathetic control. Circulation 98:2154–2159PubMedCrossRefGoogle Scholar
  18. 18.
    Bou-Holaigh I, Rowe P, Kan J, Calkins H (1995) The relationship between neurally mediated hypotension and chronic fatigue syndrome. JAMA 274:961–967CrossRefGoogle Scholar
  19. 19.
    Low P, Gilden J, Freeman R, Sheng KN, McElligott MA (1977) Efficacy of midodrine vs placebo in neurocardiogenic orthostatic hypotension. JAMA 277:1046–1051CrossRefGoogle Scholar
  20. 20.
    Ward CR, Gray JC, Gilroy JJ, Kenny RA (1998) Midodrine: a role in the management of neurocardiogenic syncope. Heart 79:45–49PubMedGoogle Scholar
  21. 21.
    Brignole M, Menozzi C, Lolli G, Bottoni N, Gaggioli G (1992) Long-term outcome of paced and non-paced patients with severe carotid sinus syndrome. Am J Cardiol 69:1039–1043PubMedCrossRefGoogle Scholar
  22. 22.
    Gaggioli G, Brignole M, Menozzi C, Devoto G, Gianfranchi L, Gostoli E, Bottoni N, Lolli G (1995) A positive response to head-up tilt test predicts syncopal recurrence in carotid sinus syndrome patients treated with permanent pacemakers. Am J Cardiol 76:720–722PubMedCrossRefGoogle Scholar
  23. 23.
    Brignole M, Menozzi C, Gianfranchi L, Lolli G, Bottoni N, Oddone D (1992) A controlled trial of acute and long-term medical therapy in tilt-induced neurally-mediated syncope. Am J Cardiol 70:339–342PubMedCrossRefGoogle Scholar
  24. 24.
    Morillo C, Leitch J, Yee R, Klein G (1993) A placebo-controlled trial of intravenous and oral disopyramide for prevention of neurally-mediated syncope induced by head-up tilt. J Am Coll Cardiol 22:1843–1848PubMedCrossRefGoogle Scholar
  25. 25.
    Di Gerolamo E, Di Iorio C, Sabatini P, Leonzio I, Barsotti A (1998) Effects of different treatments versus no treatment on neurocardiogenic syncope. Cardiologia 43:833–837Google Scholar
  26. 26.
    Raviele A, Brignole M, Sutton R, Alboni P, Giani P, Menozzi C, Moya A (1999) Effect of etilefrine in preventing syncopal recurrence in patients with tilt-induced vasovagal syncope. A double-blind, randomized, placebo-controlled trial. Circulation (in press)Google Scholar
  27. 27.
    Connolly S, Sheldon R, Roberts R, Gent M (1999) The North American Pacemaker Study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope. J Am Coll Cardiol 33:16–20PubMedCrossRefGoogle Scholar
  28. 28.
    Sutton R, Brignole M, Menozzi C, Raviele A, Alboni P, Giani P, Moya A (1999) Dualchamber pacing is efficacious in treatment of neurally mediated tilt-positive cardioinhibitory syncope. Pacemaker versus no therapy: a multicentre randomized study (in press)Google Scholar
  29. 29.
    Ector H, Reybrouck T, Heidbuchel H, Van de Werf F (1998) Tilt training: a new treatment for neurocardiogenic syncope. Arch Mal Coeur Vaisseaux 91:32 (abstr)Google Scholar
  30. 30.
    Mathias CJ (1995) The classification and nomenclature of autonomic disorders: ending chaos, restoring conflict, and hopefully achieving clarity. Clin Auton Res 5:307–310PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2000

Authors and Affiliations

  • M. Brignole
    • 1
  • C. Menozzi
    • 2
  • A. Del Rosso
    • 3
  • S. Costa
    • 1
  • G. Gaggioli
    • 1
  • A. Solano
    • 1
  • N. Bottoni
    • 2
  • P. Bartoli
    • 3
  • R. Sutton
    • 4
  1. 1.Sezione di AritmologiaOspedali RiunitiLavagnaItaly
  2. 2.Sezione di AritmologiaOspedale S. Maria NuovaReggio EmiliaItaly
  3. 3.Reparto di CardiologiaOspedale S. Pietro IgneoFucecchio (FI)Italy
  4. 4.Department of CardiologyRoyal Brompton HospitalLondonUK

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