Value of head-up tilt testing potentiated with sublingual nitroglycerin to assess the origin of unexplained syncope
Abstract
This study was undertaken to assess the value of sublingual nitroglycerin administration during upright tilt as a simple practical test for the diagnosis of vasovagal syncope. To this purpose, 235 patients with syncope of unknown origin and no evidence of organic heart disease (110 men, mean age 52 +/- 20 years) and 35 asymptomatic control subjects underwent head-up tilt testing with nitroglycerin challenge. Patients and subjects were tilted at 60 degrees for 45 + 20 minutes; the initial 45 minutes were without medication and the final 20 minutes after 300 micrograms of sublingual nitroglycerin. During the drug-free phase of the test, 59 patients (25%) and no controls had a positive response. After drug administration, a positive response (syncope in association with sudden hypotension and bradycardia) occurred in 60 patients (26%) and in 2 controls (6%), whereas an exaggerated or false-positive response (minor or different symptoms in association with slowly increasing hypotension alone) was observed in 33 patients (14%) and in 5 controls (14%). We conclude that the sublingual nitroglycerin head-up tilt test is a useful tool to unmask the vasovagal origin of unexplained syncope in patients without organic heart disease. The addition of nitroglycerin to upright tilt allows the positive rate of passive tilting to be doubled (51% vs 25%) while maintaining a high specificity (94% vs 100%).
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Tilt testing was positive in 51-56% of patients with atypical clinical features suggesting a reflex mechanism.
“Indeed, tilt testing was positive in 51-56% of patients with atypical clinical features suggesting a reflex mechanism, 106,124-128”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [128]
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- Authors
- Raviele, A., Menozzi, C., Brignole, M., Gasparini, G., Alboni, P., Musso, G., Lolli, G., Oddone, D., Dinelli, M., & Mureddu, R.
- Affiliations
- Santa Maria Nuova Hospital (IT)
- Corresponding author
- Raviele, Antonio
- Venue
- The American Journal of Cardiology
- Publisher
- Elsevier BV
- Published
- 1995-08
- Volume
- 76
- Issue
- 4
- Pages
- 267-272
- ISSN
- 0002-9149 (ISSN-L)
- OpenAlex
- W2070267385
- Cited by
- 249
- References
- 29
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 3 · 2023: 4 · 2022: 3 · 2021: 5 · 2020: 6 · 2019: 6 · 2018: 5 · 2017: 9 · 2016: 6 · 2015: 5 · 2014: 5 · 2013: 9 · 2012: 6
- FWCI
- 10.76
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The American Journal of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Life Sciences › Neuroscience › Neurology › Vestibular and auditory disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- unexplained syncope, vasovagal syncope, head-up tilt, sublingual nitroglycerin, hypotension, bradycardia, diagnostic accuracy, false positives
- MeSH terms
- Administration, Sublingual, Adolescent, Adult, Aged, Aged, 80 and over, Blood Pressure, Child, Evaluation Studies as Topic, Female, Nitroglycerin, Heart Rate, Humans, Male, Middle Aged, Sensitivity and Specificity, Syncope, Vagus Nerve, Tilt-Table Test
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