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TILTTABLE TESTING

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Syncope is defined as a sudden, brief transient loss of consciousness ... RESUSCITATION TROLLEY AVAILABLE ALWAYS. TESTS ARE DONE IN THE CARDIO-RESPIRATORY DEPT. ... – PowerPoint PPT presentation

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Title: TILTTABLE TESTING


1
TILT-TABLE TESTING CAROTID SINUS
HYPERSENSITIVITY
  • BELLA RICHARD
  • ASSOCIATE SPECIALIST
  • NEVILL HALL HOSPITAL

2
  • Syncope is defined as a sudden, brief transient
    loss of consciousness associated with loss of
    postural tone with spontaneous recovery
  • Syncope is a big problem
  • Great cause of anxiety among patients, carers and
    treating physicians
  • 3 AE visits annually
  • 6 hospital admissions annually
  • May be the only warning episode before sudden
    cardiac death.
  • Common cause of unexplained elderly falls

3
CAUSES OF SYNCOPE
  • CVS -13.2
  • UNKNOWN CAUSES -31
  • STROKE/TIA - 4.3
  • SEIZURE DISORDER - 7.2
  • VASOVAGAL - 20
  • ORTHOSTATIC CAUSE -9
  • MEDICATION -6.3
  • OTHER CAUSES -9.5

4
TILT TABLE TESTING
  • Ancient test-used in experiments to study bodys
    response to posture
  • Since 1986- used as an evaluation tool for
    syncope
  • Now gold-standard

5
PHYSIOLOGICAL BASIS
  • On standing 300-800mls of blood is displaced
    downwards
  • In seconds mechano-receptors in the vasculature
    compensate by increasing sympathetic tone -
    vasoconstriction and increased cardiac output
  • Orthostatic stabilisation occurs within 60 secs
  • Neurally mediated response

6
  • Tilt table test examines this neuro-cardiovascular
    response in a maximally controlled environment.
  • Tilt angle -700 angle of maximal passive
    orthostatic stress
  • Tilt duration 10min supine followed by 40 min
    tilted.
  • ?pharmacological stimulation- nitroglycerine,
    isoproterenol, epinephrine ( increases
    sensitivity at the expense of specificity)

7
INDICATIONS AND CONTRA INDICATIONS FOR HUT
  • INDICATIONS -, RECURRENT SYNCOPE OR PRESYNCOPE

  • SINGLE SYNCOPE WITH SERIOUS CONSEQUENCES
  • AUTONOMIC FUNCTION TESTS
  • SITUATIONAL SYNCOPE
  • OH
  • POTS
  • CAROTID SINUS HYPERSENSITIVITY.
  • CONTRAINDICATIONS - SEVERE LV OUTFLOW
    OBSTRUCTION, SEVERE CORONARY /CAROTID STENOSIS

8
Five responses
  • Neurocardiogenic syncope symptomatic sudden
    drop in BP after 10 mins associated with
    bradycardia.
  • These patients are well between turns.

9
  • Dysautonomic response - gradual
    decrease in BP to a hypotensive level leading to
    LOC. HR will not rise significantly.
  • These patients have other features like abnormal
    sweating, thermal intolerance, bowel symptoms.
  • POTS - mild form of autonomic dysfunction in
    which excessive increase in HR cannot compensate
    for low peripheral vascular resistance. Patients
    increase HR to gt30/min in 10 min of upright
    posture

10
  • Patients have near syncope, palpitations, fatigue
  • Cerebral syncope - Research centres doing TTT and
    transcranial dopplers found a small number of
    patients having cerebral vasoconstriction with no
    hypotension and bradycardia.
  • Psychogenic or psychosomatic response - patient
    has vague symptoms but no findings. Patients
    often have coexisting psychiatric disorders.

11
CAROTID SINUS HYPERSENSITIVITY.
  • COMMON CAUSE OF SYNCOPE IN ELDERLY PATIENTS
  • UNDIAGNOSED IN UPTO 50 OF PATIENTS.
  • NOT EASILY REPRODUCIBLE.
  • NEEDS REPEATED TESTING TO ENSURE PICK UP.

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13
  • POSITIVE TEST COULD BE
  • VASODEPRESSOR,
  • CARDIOINHIBITORY OR A
  • MIXED RESPONSE.
  • DIAGNOSE IF gt 3SECS ASSYSTOLE OR 50 MM HG DROP
    IN SYSTOLIC BP.
  • DUAL CHAMBER PACING IN THESE PATIENTS PRODUCES
    SYMPTOMATIC RELEIF IN 90 PATIENTS.
  • OVERLAP EXISTS BETWEEN CSH AND VASOVAGAL
    SYNCOPE.

14
INDICATIONS AND CONTRAINDICATIONS FOR CSM
  • INDICATIONS - OLDER PATIENTS WITH SYNCOPE ,
    UNEXPLAINED FALLS
  • CONTRAINDICATIONS - TIA / MI /STROKE IN THE PAST
    3 MONTHS
  • PREVIOUS VF ARREST
  • CAROTID BRUITS / CAROTID STENOSIS gt 70
  • LESS SEVERE CAROTID STENOSIS ONLY SUPINE CSM

15
PROTOCOLS
  • PASSIVE DRUG FREE TILT
  • 40 MIN AT 70 DEGREES HEAD UP TILT
  • REST PATIENT FOR 20 MIN PRIOR TO TESTING
  • CAROTID SINUS MASSAGE BEFORE TILTING AND AFTER 40
    MIN HEAD UP TILT
  • CONSENT OBTAINED FOR CAROTID SINUS MASSAGE

16
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18
Staffing levels
  • TWO OPERATORS MUST BE PRESENT OF WHICH ONE MUST
    BE TRAINED IN ACLS
  • RESUSCITATION TROLLEY AVAILABLE ALWAYS
  • TESTS ARE DONE IN THE CARDIO-RESPIRATORY DEPT.
  • ONE AFTERNOON SESSION PER WEEK
  • NOT MORE THAN THREE PATIENTS PER SESSION

19
Syncope in the Older AdultDiagnostic Evaluation
  • Pursue witness accounts when possible
  • Include in history taking
  • social circumstances, injurious events, impact of
    events on confidence, ability to perform ADLs
    independently
  • Determine timing of syncope occurrence
  • orthostatic hypotensive events usually occur in
    the AM
  • Association with meals, medications, nocturnal
    micturition, etc.
  • Detailed medication history
  • Co-morbid diagnoses (especially Parkinsons,
    diabetes, anaemia, hypertension, ischaemic heart
    disase, heart failure)

20
Syncope in the Older AdultExamination
  • Assessment of neurological and locomotor systems
  • Including observation of gait and standing
    balance (eyes open eyes closed)
  • Determine if cognitive impairment is present
    (mini-mental state examination)

21
Syncope in the Older AdultInvestigations
  • The diagnostic evaluation should include the same
    basic components as for younger adult
  • Exception is routine supine and upright carotid
    sinus massage
  • Repeated morning measurements are recommended to
    determine if orthostatic hypotension exists
  • 24-hr ambulatory BP may be helpful if meals or
    medications are suspected
  • If symptoms continue, or gt 1 cause is suspected,
    further evaluation is indicated

22
Syncope in the Older AdultEvaluation of the
Frail and Elderly
  • The rigour of assessment should depend on
    compliance with tests and on prognosis
  • For patients who have difficulty standing
    unaided, head-up tilt can be used to assess
    orthostatic changes
  • Clinical decisions regarding the value of a
    syncope evaluation should be made for each
    patient based on the benefits to the individual

23
Syncope in the Older AdultConclusions
  • Class I Recommendations
  • Morning orthostatic blood pressure measurements
    and supine and upright carotid massage are
    integral to the initial evaluation unless
    contraindicated.
  • The evaluation of mobile, independent,
    cognitively normal older adults is as for younger
    individuals.
  • In frailer older adults, evaluation should be
    modified according to prognosis.

24
CASE 3
  • 74 yr old lady
  • 3 blackouts, always in church!
  • 24 hr ECG normal.
  • No postural BP deficit.
  • Subjected to tilting Jan 2002.
  • CSM supine - NAD.
  • 30 min hut did not produce any change in HR or
    BP.
  • CSM at the end of tilting time produced 4.2 SEC
    pause
  • Also hypotension bp decreased from 137/78 to
    88/59.
  • Patient had syncope!

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26
CASE 2
  • Mrs IT, 69 yr lady with recurrent blackouts.
  • Seen by ENT ?right hearing loss ?Cause
  • Seen by neurologist ?cerebrovascular disease. MRI
    brain confirmed deep white matter lesions /small
    vessel ischaemia.
  • Still continuing to have black outs
  • 24 hour ECG normal.
  • Subjected to tilt table test in nov 2001
  • Carotid sinus massage nad
  • 18 minutes into tilting heart rate dropped to
    48/min, BP dropped to 76/34 and patient lost
    consciousness.
  • Recovered on assuming supine position.
  • ?Neurocardiogenic syncope.

27
  • Commonest cause of syncope in all age groups.
  • Underdiagnosed problem.
  • Characterised by bradycardia, hypotension or both
    during symptoms.
  • In normal individuals- upright position increases
    venous pooling, this leads to increase in heart
    rate and compensatory vasoconstriction.
    Underfilled ventricle then contracts vigorously
    and thus activates the afferent mechanoreceptors.
  • In patients with NCS- this rapid increase in
    afferent neural activity produces a centrally
    mediated paradoxical decrease in heart rate and
    peripheral vasodilatation leading to hypotension.
  • Tilt table testing is the investigation of choice.

28
TREATMENT
  • Medical management-
  • Beta blockers- supresses response to circulating
    catecholamines
  • Theophyllines- as above.
  • Fludrocortisone- volume expansion
  • SSRI- central acting- modifies the baroreceptor
    response.
  • Midodrine- a specific adrenergic receptor agonist
    with low side effect profile. It binds to
    peripheral receptors and increases vascular tone.
  • Pacemakers-for patients with predominant
    cardioinhibition.
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