Bravo Newcastle!

Tilt training was introduced in Belgium, 1 where the healthcare environment is special in many ways. Patients with severe vasovagal syncope were admitted to hospital and tilted daily until they ceased to faint. This was a completely novel approach unattainable in most healthcare systems due to bed unavailability. The results were very encouraging, but many felt that this was a form of aversion therapy. As the Leuven group extended their experience, the technique was seen to work at home after an in-hospital period. 2 Provided that the patient maintained their standing training on a daily basis most remained symptom-free. Their reports encouraged others to attempt it and the results were disappointing mainly because of poor compliance with, as might be expected, better results in Japan than in Italy. 3 , 4 There seemed to be no easy way of performing a blinded, randomized, controlled trial. Efforts were made to show that the prolonged erect position had a favourable effect on the autonomic nervous system. 5 When the European Society of Cardiology's Task Force on Syncope met in 2008–9, the evidence in favour of recommending tilt training was felt to be weak and the latest Guidelines do not give much importance to this technique. 6 The thinking of members of the Task Force was that tilt training may work but compliance is essential and is a problem in most environments. Furthermore, the autonomic basis of benefit is ill understood. In Tan et al. , 7 the authors have given a thought provoking study of tilt training appropriately renamed by them as home orthostatic training (HOT). The Newcastle group has made an important contribution to this field in two ways. First, they have devised a convincing and acceptable placebo for HOT and, secondly, they have made autonomic nervous system measurements serially and simply, which, in this pilot study, show evidence of benefit in comparison with placebo that justifies a larger study. The Newcastle group rightly points out that our therapeutic armamentarium is limited in vasovagal syncope. Therefore, we will all be grateful to have the much needed evidence to pursue this form of therapy. As has been emphasized by the group, there is now a need for a large study involving many centres in many countries to give it a wide basis for acceptance. Any study in vasovagal syncope needs to be for at least 1 year so as to be able to overcome the huge variability in symptom occurrence and in cluster presentations. With such a necessary length of study, compliance will be a great problem. The small, but expanding, medical community with a deep interest in syncope will stand to gain in their management of patients from a proven therapy that hands control back to the patient and offers something extra over and above increased fluid and salt consumption, anticipation, and avoidance of triggering events and physical counter measures. 6 , 8 Conflict of interest: none declared.