Overview of Tilt Table

Syncope is a condition that can cause fainting or passing out because the heart and blood vessels aren’t being properly controlled by the body’s automatic nervous system and hormones. To diagnose this, doctors can use a “tilt table test”. The tilt table test is a medical procedure that tests for the cause of fainting spells. The patient is placed on a table, secured, and then tilted to simulate standing up. During this test, the patient undergoes orthostatic stress – stress endured by the body when changing position from lying down to standing up.

Sometimes, doctors can make this stress stronger by using certain medications like nitroglycerin, clomipramine, and isoprenaline. If the tilt table test shows a small increase in heart rate and a stable blood pressure above 90 mmHg without any symptoms like dizziness or fainting, then the result of the test is negative.

Sometimes, a tilt table test can trigger a neurocardiogenic reflex – a sudden drop in the heart rate and blood pressure leading to fainting. There can also be other positive responses such as sudden low blood pressure on standing up, persistent low blood pressure on standing up, and rapid heart rate on standing up. On the other hand, there are cases where the heart rate does not increase as much as it should – a condition known as ‘chronotropic incompetence’.

It’s important to note that while the tilt table test can show proneness to fainting due to low blood pressure, it doesn’t always identify the exact reason behind the fainting.

During the test, a patient might experience what appears to be a fainting episode where they might go silent, drop their head, and close their eyes tightly, but this is not associated with a real fainting episode as the patient can still maintain an upright position, and their blood pressure and heart rate remain normal. This is often referred to as pseudo-syncope.

Anatomy and Physiology of Tilt Table

When the body is in a tilted position, such as when standing up, blood tends to flow into the veins in the abdomen and legs. This causes a reduction in the amount of blood in the central part of the body, which includes the heart and brain. To compensate for this change, the nervous system releases various hormones to help maintain stability, referred to as homeostasis.

The activation of these hormones and other nervous system responses may not be sufficient, leading to a drop in blood pressure. Some unknown processes may trigger a reaction or reflex, leading to the expansion of blood vessels and a decrease in heart activity. This reaction can be triggered both at the level of the body and in the brain.

Dehydration makes a person more susceptible to these changes, especially during a medical test. Inserting a vein catheter or even just being in a medical environment can also induce this reaction.

The person may start to experience warning signs such as sweating, blurry vision, hot and cold flashes, weakness, loss of hearing, and nausea before fainting. Sometimes, the person may lose consciousness suddenly even if signs like slow decrease in blood pressure and heart rate are present. Unconsciousness typically lasts for around 20 seconds but can last longer in some cases. During fainting, it’s common for the person to keep their eyes open, and they may exhibit incontinence, abnormal movements, eye deviations, and vocalizing sounds. They also are unable to hold an upright position and will fall if they aren’t supported by something like a belt.

After coming to, the person may remember or share dream-like thoughts, particularly if they were unconscious for an extended time. Some people may deny all loss of consciousness but cannot remember specifics such as when they were moved to a laying position during the medical test.

It’s also common to feel nausea and vomiting after fainting. This can last for up to 15 to 30 minutes. Some people report feelings of weakness that can persist for several hours, but typically people can stand up again after approximately 10 to 15 minutes.

Why do People Need Tilt Table

The tilt table test is another step taken when doctors try to find out the cause of fainting or sudden loss of consciousness (also referred to as syncope). The first steps when you’re being looked into for fainting involve checking your medical history, a physical check-up, an orthostatic test (which involves checking your blood pressure when you’re lying down and again a few minutes after you stand up), and an EKG (a test to check your heart’s electrical activity).

Doctors then decide to do a tilt table test in cases where:

  • You have fainted on more than one occasion, and they can’t pinpoint why
  • You’ve injured yourself while fainting, yet the cause of fainting is still unknown
  • You’ve fainted only once, but there were no warning signs before it happened, and the cause is still unknown
  • They think that you may be fainting due to psychological reasons, rather than physical
  • You had jerky movements when you fainted, and they want to rule out epilepsy (which is a neurological disorder)
  • You fell down, but they suspect that it may have been due to a fainting spell.

This procedure is safe and can help doctors understand why you’ve been fainting or losing consciousness, which can then guide them in coming up with the right treatment for you.

When a Person Should Avoid Tilt Table

There are certain conditions which may prevent a patient from undergoing a tilt test. These include significant narrowing of the carotid artery (a key blood vessel in the neck), or of the coronary arteries, which supply blood to the heart. Additionally, individuals with a heart condition known as hypertrophic cardiomyopathy, characterized by a thickened heart muscle and narrowed exit path for blood, may not be suitable for this test.

Other situations where the test might not be suitable are when a patient has very low levels of red blood cells, a condition known as severe anemia, or when the cause of the patient’s fainting spell (also known as a syncopal event) is already known. Similarly, if a patient does not have a history of fainting, falls, or dizzy spells (pre-syncopal events), the tilt test may not be necessary.

Finally, if a patient’s overall health condition isn’t stable, it might not be safe or appropriate to administer this test.

Equipment used for Tilt Table

The tilt table test, a procedure used to find out why people may be fainting or feeling lightheaded, requires specific equipment. This includes a tilt table, which is a table that moves you from a horizontal to a vertical position. Other essential tools are a blood pressure monitor, which measures your blood pressure, and an ECG monitor, used to track the rhythm and electrical activity of your heart.

During this test, medications like nitroglycerin (a heart medicine often provided in a spray form), isoprenaline (a medicine used to increase heart rate, typically given through an infusion, which is a slow injection into a vein), or clomipramine (an injection used for treating different health conditions) might be used. Additionally, a cardioverter-defibrillator is also needed. This device can give your heart electric shocks to restore a normal rhythm if there are any dangerous irregularities.

Who is needed to perform Tilt Table?

The tilt table test is usually done by a qualified nurse, a doctor, or sometimes even both, depending on local legal requirements. The persons doing the test need to be officially approved and must have the necessary skills to perform basic life-saving techniques, if the situation calls for it. Essentially, they know how to act quickly and efficiently to keep you safe in case something unexpected happens during the test.

Preparing for Tilt Table

Before undergoing a medical examination, it’s necessary for a patient to not consume any food or drink for a minimum of 4 hours. This is done to prevent the possibility of choking on food or drink, in the unlikely event that the patient vomits while unresponsive. For the examination, the patient can wear their regular clothes.

For better preparation, it’s vital to explain to the patient about what the procedure involves and what they can expect during the process. This can help minimize any unnecessary worry or stress about the test. In addition, patients should be aware that there is a risk of them experiencing an urge to vomit or losing bladder control, and for this reason, they should bring a change of clothes just in case.

How is Tilt Table performed

Before a tilt table test, it’s important that you lie flat on your back for at least 5 minutes. If a need arises to insert a tube into your vein (venous catheterization) before the test, you might need to lie in this position for a bit longer. During the test, you’ll be safely strapped in to prevent any falls or injuries. You should know that the venous catheterization isn’t always necessary before a tilt table test.

During the procedure, your blood pressure will be regularly checked and your heart’s activity will be observed using an electrocardiogram (or ECG, a test that checks how your heart is functioning). The best way to monitor blood pressure is through continuous non-invasive blood pressure monitoring, but a regular people’s blood pressure cuff (sphygmomanometer) can also be used.

The tilt table test will be carried out based on a specific plan or protocol. The most commonly used ones are the Westminster or the Italian protocols. The test begins with a passive phase that typically lasts between 20 to 45 minutes. Then, you might be given a medicine (often, 0.4 mg nitroglycerine placed under your tongue) to increase the effectiveness of the test. But, taking this medicine can slightly decrease the accuracy of the test. After taking the medicine, you’ll have to keep standing for up to 15 minutes.

The test ends either when you faint (syncope) or when all the steps of the protocol have been completed. Some people might experience a long-lasting decrease in blood pressure without actually fainting. If this happens, especially if you are older, the test might be stopped during the period before fainting (the pre-syncopal period).

If the result of the test is positive, you’ll be asked if you’ve felt similar symptoms in your daily routine. The table should be tilted back to the starting position rapidly, within 10 seconds. Keeping the table tilted for a longer time might cause a longer fainting episode. The changes in your blood pressure and heart rate will be evaluated throughout this process.

Possible Complications of Tilt Table

The tilt table test is generally a safe procedure used to find out why people might faint or feel lightheaded. However, rare complications can occur. For people who have significant blocking of the heart (coronary) or neck (carotid) arteries, there might be a very small risk of a heart attack or stroke. Some patients may experience a slow heart rate (bradycardia) which can be treated with a medicine called atropine. A problem where the heart beats with rapid, erratic electrical impulses (ventricular fibrillation) is extremely rare.

Some people might feel nauseous and vomit after the test or feel very weak for several hours. Headaches are also common, especially if a medication called nitroglycerin has been used. Rarely, there could be brief jerky movements of the arms or legs (myoclonus) just after fainting and before waking up (convulsive syncope). This is not the same as having seizures.

What Else Should I Know About Tilt Table?

When doctors test for heart conditions, they sometimes use a method called tilt testing. This test can reveal something called a “cardioinhibitory form of neurocardiogenic reflex”, which is a fancy way of saying that the heart slows down too much. This happens because of a reflex between the heart and the brain. Sometimes, this reflex can lead to fainting spells in patients. There is some disagreement in the medical community about how to handle these cases.

Some doctors propose inserting a pacemaker, a device that helps control abnormal heart rhythms. This has even been suggested for young people who have fainted only once. The doctors who suggest this are mainly concerned about the risk of a severe and life-threatening condition called a cardiac arrest, which happens when the heart unexpectedly stops beating. However, such an approach carries its own set of risks like infections, needing more future procedures, lower quality of life, and even mental health issues such as anxiety and depression.

The reflex mentioned above can affect either the sinus node, a section of the heart that helps control heart rate, causing it to slow down or even stop for a while, or it can affect the atrioventricular node, another part of the heart which ensures the orderly beating of the heart. If it affects the atrioventricular node, it can lead to something called an “atrioventricular block”, presenting another form of heart interruption.

Patients who experience these heart interruptions during tilt tests often have shorter warning periods before they faint. They also usually have a longer electrical wave reading (known as a PR interval) on their heart tracking tests, or electrocardiograms, at baseline.

As of now, doctors believe that the decision to place a pacemaker because of heart interruptions revealed by tilt testing should depend on the individual’s circumstances. Older patients might need to have a pacemaker because they could have other heart issues as well. However, it’s generally thought that a pacemaker is not usually necessary in patients younger than 40.

Frequently asked questions

1. What is the purpose of the tilt table test and how will it help diagnose my fainting spells or loss of consciousness? 2. Are there any risks or complications associated with the tilt table test that I should be aware of? 3. Will I need to stop taking any medications before the test? Are there any specific medications that will be used during the test? 4. How long does the tilt table test typically take and what can I expect during the procedure? 5. What are the possible outcomes or results of the tilt table test and how will they guide my treatment plan?

The tilt table can affect you by causing a reduction in blood pressure and blood flow to the heart and brain. This can lead to symptoms such as sweating, blurry vision, weakness, and nausea, and may result in fainting. After fainting, you may experience dream-like thoughts and feelings of nausea and weakness, which can last for several minutes to hours.

You may need a Tilt Table test if you have a history of fainting, falls, or dizzy spells (pre-syncopal events) and the cause of these events is not yet known. The test can help determine if your symptoms are related to a drop in blood pressure or heart rate when changing positions. However, there are certain conditions and situations where the test may not be suitable, such as significant narrowing of key blood vessels, hypertrophic cardiomyopathy, severe anemia, known cause of fainting, or unstable overall health condition. It is important to consult with your healthcare provider to determine if a Tilt Table test is appropriate for you.

You should not get a Tilt Table test if you have certain conditions such as significant narrowing of the carotid or coronary arteries, hypertrophic cardiomyopathy, severe anemia, a known cause for fainting, no history of fainting or dizziness, or if your overall health condition is unstable.

The recovery time for a Tilt Table test is typically around 10 to 15 minutes. After the test, some people may experience feelings of weakness that can persist for several hours, but they are usually able to stand up again within the first 15 minutes. It's important to note that the recovery time may vary depending on the individual and their specific circumstances.

To prepare for a Tilt Table test, it is important to not consume any food or drink for at least 4 hours before the test to prevent choking. Patients should also be aware of the possibility of experiencing an urge to vomit or losing bladder control, and should bring a change of clothes just in case. It is recommended to lie flat on your back for at least 5 minutes before the test and to wear regular clothes during the procedure.

The complications of Tilt Table include a small risk of heart attack or stroke for individuals with significant blocking of the heart or neck arteries, slow heart rate (bradycardia), rapid and erratic heartbeats (ventricular fibrillation), nausea and vomiting, weakness, headaches (especially if nitroglycerin is used), and brief jerky movements of the arms or legs (myoclonus) after fainting.

Symptoms that require a tilt table test include fainting on multiple occasions with an unknown cause, injuring oneself while fainting without a known cause, fainting without warning signs and an unknown cause, suspected psychological reasons for fainting, jerky movements during fainting to rule out epilepsy, and falling down with a suspected fainting spell.

There is no specific information provided in the given text about the safety of tilt table testing during pregnancy. It is recommended to consult with a healthcare professional for personalized advice regarding the safety and appropriateness of tilt table testing during pregnancy.

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