Key result
Shortening the active phase of the head-up tilt test with 0.4 mg nitroglycerin to 10 minutes resulted in a minimal positivity rate loss of 1.5% compared to the standard duration.
Why the study?
The European Society of Cardiology recommends a 15 to 20-minute drug challenge phase during head-up tilt testing, but the outcome and loss in positivity rate with a shortened 10-minute nitroglycerin active phase were unknown.
Does a shortened 10-minute active phase of the head-up tilt test with 0.4 mg sublingual nitroglycerin maintain diagnostic yield compared to a standard 20-minute active phase in patients with suspected vasovagal syncope?
Observational (n=306)
No
Does a shortened 10-minute active phase of the head-up tilt test with 0.4 mg sublingual nitroglycerin maintain diagnostic yield compared to a standard 20-minute active phase in patients with suspected vasovagal syncope?
Shortening the active phase of the head-up tilt test with nitroglycerin to 10 minutes is a time-saving alternative that maintains high diagnostic accuracy for vasovagal syncope.
Answers are grounded in this paper and cite their sources.
May support shorter nitroglycerin tilt protocols for efficiency; leaves open need for randomized confirmation before practice change.
Performing a head-up tilt test can be of great value for the diagnosis of vasovagal syncope. The European Society of Cardiology recommends a drug challenge phase duration of 15 to 20 minutes, with either Isoprenaline or Nitroglycerin administration.We sought to investigate the outcome of a ten-minute active phase with Nitroglycerin in patients suspected of vasovagal syncope and determine the percentage of loss in the positivity rate, using this short duration approach.We consecutively enrolled patients presenting with syncope undergoing the head-up tilt test (HUTT), with a clinical suspicion of vasovagal syncope between the years 2009 to 2019. The HUTT consisted of 2 successive phases: passive and active. During the passive phase, the patients were tilted at 70° for 20 minutes. If negative, the test was continued after administration of 0.4 mg sublingual Nitroglycerin. Applying the (VASIS) Vasovagal Syncope International Study classification of the vasovagal syncope international study and comparing for age and gender, positive responses were categorized into 3 types.A number of 306 patients (age = 43.5 +/-20.3; male = 140 [45.7%]) with suspected vasovagal syncope, undergoing HUTT, were enrolled in the years of 2009 to 2019. Of those, 245 (80.2%) presented a positive test, with 200 patients (82.0%) during the being positive during the active phase of the test. The results were as follows: 116 subjects (47.2%) presented with a mixed response (VASIS I), 52 (21.3%) showed a cardio inhibitory response (VASIS II), and 77 (31.5%) displayed a vasodepressor response (VASIS III). We found no relationship between the type of syncope with neither gender, nor age of the patient. Three minutes represented the median time to positivity, after Nitroglycerine administration. The time distribution showed a peak incidence appearing between minutes 3 and 5, ranging from 1 to 20 minutes. Only 3 patients tested positive after minute 10.Shortening the active phase to 10 minutes would result in a positivity rate loss of 1.5%.
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Glockler et al. (2020) conducted an observational in Suspected vasovagal syncope (n=306). 10-minute active phase with Nitroglycerin vs. 15-minute or 20-minute active phase was evaluated on Positivity rate during the active phase (p=0.08). Shortening the active phase of the head-up tilt test with 0.4 mg nitroglycerin to 10 minutes resulted in a minimal positivity rate loss of 1.5% compared to the standard duration.
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