© 1999 by European Society of Cardiology
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
*Arrhythmologic Center, Department of Cardiology, Ospedali Riuniti Lavagna, Italy;
Section of Arrhythmology, Department of Cardiology, Ospedale S Maria Nuova Reggio Emilia, Italy;
Section of Arrhythmology, Department of Cardiology, Ospedale S Pietro Igneo Fucecchio, Italy;
Section of Arrhythmology, Ospedale Civile Imperia, Italy;
||Department of Cardiology, Ospedate Val Duce Como, Italy;
¶Department of Cardiology, Ospedale S Raffaele Roma, Italy
BACKGROUND: Since the pharmacological challenge with nitroglycerin (NTG) follows the initial drug-free phase in current tilt testing protocols, the eVects 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° 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° 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.
Key Words: Neurally mediated syncope, tilt-table testing, nitroglycerin, Vasovagal syncope
Correspondence: Dr Angelo Bartoletti, Costa de' Magnoli 28, 50125 Firenze, Italy
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