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Head-up tilt testing potentiated with oral nitroglycerin: a randomized trial of the contribution of a drug-free phase and a nitroglycerin phase in the diagnosis of neurally mediated syncope.
Europace. 1999 Jul; 1(3):183-6.E

Abstract

BACKGROUND

Since the pharmacological challenge with nitroglycerin (NTG) follows the initial drug-free phase in current tilt testing protocols, the effects of nitroglycerin alone and the appropriate duration of the basal phase are unknown.

METHODS

To optimize the test, a randomized intra-patient comparison of two protocols was undertaken: a conventional nitroglycerin test (cHUT) consisting of passive upright posture at 60 degrees for 45 min followed, if negative, by sublingual NTG 0.4 mg spray, with the test continued for 20 min; and, accelerated nitroglycerin test (aHUT) consisting of passive upright posture at 60 degrees for 5 min--to rule out orthostatic hypotension--followed by sublingual NTG 0.4 mg spray, with the test continued for 20 min. Eighty-four consecutive patients (33 males; mean age 55+/-22) with unexplained syncope underwent both cHUT and aHUT in a randomized sequence with a 24-72 h interval between them. Additionally, 25 age-matched control subjects underwent aHUT.

RESULTS

In the drug-free phase, cHUT was positive in 15/84 patients (18%) and aHUT in 1/84 patients (1%). After NTG, cHUT and aHUT showed the same positivity rate of 33% (28/84 patients). The overall positivity rate was therefore higher with cHUT than with aHUT (51% vs 35%, P=0.04). Times to syncope were 29+/-12 min, (range 2-44) for cHUT drug-free phase, 5+/-2 min (range 2-9) for cHUT NTG phase, and 5+/-2 min (range 2-9) for aHUT. Only one (4%) of the control subjects had a positive response to aHUT.

CONCLUSIONS

The contribution of NTG to the diagnosis is independent of the presence of an unmedicated phase. The appropriate duration of the NTG phase is 10 min. aHUT has good specificity, but a positivity rate lower than cHUT; thus a drug-free phase is necessary to increase the sensitivity of the test.

Authors+Show Affiliations

Bartoletti A
Arrhythmologic Center, Department of Cardiology, Ospedali Riuniti, Lavagna, Italy.
Gaggioli G
No affiliation info available
Menozzi C
No affiliation info available
Bottoni N
No affiliation info available
Del Rosso A
No affiliation info available
Mureddu R
No affiliation info available
Musso G
No affiliation info available
Foglia-Manzillo G
No affiliation info available
Bonfigli B
No affiliation info available
Brignole M
No affiliation info available

MeSH

Administration, OralAdolescentAdultAgedAged, 80 and overFemaleHumansMaleMiddle AgedNitroglycerinSyncope, VasovagalTilt-Table Test

Pub Type(s)

Clinical Trial
Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

11225795

Citation

Bartoletti, A, et al. "Head-up Tilt Testing Potentiated With Oral Nitroglycerin: a Randomized Trial of the Contribution of a Drug-free Phase and a Nitroglycerin Phase in the Diagnosis of Neurally Mediated Syncope." Europace : European Pacing, Arrhythmias, and Cardiac Electrophysiology : Journal of the Working Groups On Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology, vol. 1, no. 3, 1999, pp. 183-6.
Bartoletti A, Gaggioli G, Menozzi C, et al. Head-up tilt testing potentiated with oral nitroglycerin: a randomized trial of the contribution of a drug-free phase and a nitroglycerin phase in the diagnosis of neurally mediated syncope. Europace. 1999;1(3):183-6.
Bartoletti, A., Gaggioli, G., Menozzi, C., Bottoni, N., Del Rosso, A., Mureddu, R., Musso, G., Foglia-Manzillo, G., Bonfigli, B., & Brignole, M. (1999). Head-up tilt testing potentiated with oral nitroglycerin: a randomized trial of the contribution of a drug-free phase and a nitroglycerin phase in the diagnosis of neurally mediated syncope. Europace : European Pacing, Arrhythmias, and Cardiac Electrophysiology : Journal of the Working Groups On Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology, 1(3), 183-6.
Bartoletti A, et al. Head-up Tilt Testing Potentiated With Oral Nitroglycerin: a Randomized Trial of the Contribution of a Drug-free Phase and a Nitroglycerin Phase in the Diagnosis of Neurally Mediated Syncope. Europace. 1999;1(3):183-6. PubMed PMID: 11225795.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Head-up tilt testing potentiated with oral nitroglycerin: a randomized trial of the contribution of a drug-free phase and a nitroglycerin phase in the diagnosis of neurally mediated syncope. AU - Bartoletti,A, AU - Gaggioli,G, AU - Menozzi,C, AU - Bottoni,N, AU - Del Rosso,A, AU - Mureddu,R, AU - Musso,G, AU - Foglia-Manzillo,G, AU - Bonfigli,B, AU - Brignole,M, PY - 2001/2/28/pubmed PY - 2001/5/1/medline PY - 2001/2/28/entrez SP - 183 EP - 6 JF - Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology JO - Europace VL - 1 IS - 3 N2 - BACKGROUND: Since the pharmacological challenge with nitroglycerin (NTG) follows the initial drug-free phase in current tilt testing protocols, the effects of nitroglycerin alone and the appropriate duration of the basal phase are unknown. METHODS: To optimize the test, a randomized intra-patient comparison of two protocols was undertaken: a conventional nitroglycerin test (cHUT) consisting of passive upright posture at 60 degrees for 45 min followed, if negative, by sublingual NTG 0.4 mg spray, with the test continued for 20 min; and, accelerated nitroglycerin test (aHUT) consisting of passive upright posture at 60 degrees for 5 min--to rule out orthostatic hypotension--followed by sublingual NTG 0.4 mg spray, with the test continued for 20 min. Eighty-four consecutive patients (33 males; mean age 55+/-22) with unexplained syncope underwent both cHUT and aHUT in a randomized sequence with a 24-72 h interval between them. Additionally, 25 age-matched control subjects underwent aHUT. RESULTS: In the drug-free phase, cHUT was positive in 15/84 patients (18%) and aHUT in 1/84 patients (1%). After NTG, cHUT and aHUT showed the same positivity rate of 33% (28/84 patients). The overall positivity rate was therefore higher with cHUT than with aHUT (51% vs 35%, P=0.04). Times to syncope were 29+/-12 min, (range 2-44) for cHUT drug-free phase, 5+/-2 min (range 2-9) for cHUT NTG phase, and 5+/-2 min (range 2-9) for aHUT. Only one (4%) of the control subjects had a positive response to aHUT. CONCLUSIONS: The contribution of NTG to the diagnosis is independent of the presence of an unmedicated phase. The appropriate duration of the NTG phase is 10 min. aHUT has good specificity, but a positivity rate lower than cHUT; thus a drug-free phase is necessary to increase the sensitivity of the test. SN - 1099-5129 UR - https://www.unboundmedicine.com/medline/citation/11225795/Head_up_tilt_testing_potentiated_with_oral_nitroglycerin:_a_randomized_trial_of_the_contribution_of_a_drug_free_phase_and_a_nitroglycerin_phase_in_the_diagnosis_of_neurally_mediated_syncope_ DB - PRIME DP - Unbound Medicine ER -