Nitroglycerin-provoked head-up tilt testing yielded the most diagnoses (median 64.2%) in older syncope patients, with no consistent evidence that positivity rates differ from younger patients.
Systematic Review (n=12,378)
Does head-up tilt testing (HUTT) have different positivity rates and diagnostic yields in older syncope patients compared to younger patients?
Head-up tilt testing, particularly with nitroglycerin provocation, is safe and provides a high diagnostic yield for unexplained syncope in older patients, comparable to its utility in younger patients.
BACKGROUND: In older syncope patients, medical histories are often less reliable due to retrograde amnesia and cognitive impairment. Therefore, additional tests may be needed to reach a diagnosis. We conducted a systematic review to evaluate positivity rates and safety of head-up tilt testing (HUTT) in these patients. METHODS: We searched Medline and Embase for HUTT positivity rates and diagnoses in older syncope patients (mean age ≥ 65 years) vs. younger patients. Secondary outcomes were time to syncope (TtS) and adverse events (AEs). Risk of bias was assessed with a modified version of the QUADAS-2. RESULTS: In total, 42 studies were included, with 12 378 older participants in total. Positivity rates varied widely passive HUTT 0.0%-90.0%; isoproterenol (IPR)-HUTT 18.3%-64.0%; nitroglycerin-HUTT 30.1%-90.5%. The majority of studies found no differences between older and younger patients. Specificity was high for all HUTT-protocols (85.5%-100%). TtS did not differ between older and younger patients, but was significantly longer in control subjects. Nitroglycerin-HUTT yielded the most diagnoses (median 64.2% vs. 23.7% for passive, P = .007, and 44.8% for IPR-HUTT, n.s.). Vasodepressive responses were more common than cardioinhibitory responses (median 54.9% vs. 9.1%) in older patients. AEs occurred in <6% of patients with passive/nitroglycerin-HUTT. DISCUSSION/CONCLUSION: There is no consistent evidence that HUTT results differ between older and younger syncope patients. Nitroglycerin-HUTT yields the most diagnoses, whilst retaining a high specificity, and is safe to perform in older patients. Future studies should focus on the additional value of HUTT on top of the initial evaluation in these patients.
Ruiter et al. (Fri,) conducted a systematic review in Unexplained syncope (n=12,378). Head-up tilt testing (HUTT) with or without pharmacological provocation vs. Younger syncope patients and/or healthy age-matched controls was evaluated on Positivity rates and distribution of diagnoses established by HUTT. Nitroglycerin-provoked head-up tilt testing yielded the most diagnoses (median 64.2%) in older syncope patients, with no consistent evidence that positivity rates differ from younger patients.