‘The Italian Protocol‘: a simplified head-up tilt testing potentiated with oral nitroglycerin to assess patients with unexplained syncope
Open accessAbstract
Head-up tilt testing potentiated by sublingual nitroglycerin (NTG), advocated by an Italian group, is a simple and safe but still not a standardized, diagnostic tool for the investigation of syncope. In fact, owing to its rapid spread, the original protocol received, often arbitrarily, many subsequent modifications. We now define the best methodology of the test on strictly evidence-based criteria as: stabilization phase of 5 min in the supine position; passive phase of 20 min at a tilt angle of 60 degrees; provocation phase of further 15 min after 400 micrograms NTG sublingual spray. Test interruption is made when the protocol is completed in the absence of symptoms, or there is occurrence of syncope, or occurrence of progressive (> 5 min) orthostatic hypotension. We intend that this protocol, named by us as 'The Italian Protocol', will be accepted as the standard methodology of the tilt test potentiated by sublingual nitrates.
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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 [106]
The Additional information table reports 51% total tilt-test positivity in two groups of patients with unexplained syncope. It does not identify those patients as having atypical clinical features suggesting a reflex mechanism, or report a 56% positivity rate for that subgroup. The Test interruption section describes a positive response as an expression of a vasovagal reflex, but does not establish the claimed subgroup rate. (LLM, conf=0.84)
Experimental — accuracy not yet measuredTilt testing has an acceptable sensitivity and specificity when calculated in patients with true VVS or without a history of syncope.
“Tilt testing has an acceptable sensitivity 124 and specificity 106,124,125 when these are calculated in patients with true VVS or without a history of syncope.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [106]
The Additional information tables report positive tilt tests in patients with unexplained syncope and relatively few positive tests in control subjects (18 of 230), supporting the general point about diagnostic performance. The paper does not establish sensitivity specifically in patients with confirmed, or “true,” vasovagal syncope; its patient results concern unexplained syncope. Page numbers are unavailable in our copy. (LLM, conf=0.85)
Experimental — accuracy not yet measured
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- Authors
- Bartoletti, A.
- Affiliations
- Ospedale Santa Maria Annunziata (IT)
- Corresponding author
- Bartoletti, A
- Venue
- Europace
- Publisher
- Oxford University Press (OUP)
- Published
- 2000-10
- Volume
- 2
- Issue
- 4
- Pages
- 339-342
- ISSN
- 1099-5129 (ISSN-L)
- OpenAlex
- W2128037753
- Cited by
- 315
- References
- 17
- Citations by year
- 2026: 14 · 2025: 18 · 2024: 12 · 2023: 20 · 2022: 17 · 2021: 13 · 2020: 15 · 2019: 9 · 2018: 16 · 2017: 14 · 2016: 13 · 2015: 13 · 2014: 10 · 2013: 22 · 2012: 13
- FWCI
- 5.40
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- EP Europace (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
- head-up tilt, sublingual nitroglycerin, syncope, orthostatic hypotension, orthostatic intolerance
- MeSH terms
- Administration, Oral, Adult, Aged, Female, Nitroglycerin, Humans, Italy, Male, Middle Aged, Sensitivity and Specificity, Syncope, Vasodilator Agents, Tilt-Table Test
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