Tilt Test as a Primary Non-Invasive Method for Testing Cardiac Autonomic Nervous System Function in Patients with Vasovagal Syncope

DOI: https://doi.org/10.63181/ujcvs.2025.33(3).106-111
Keywords: loss of consciousness, diagnosis of reflex syncope, conservative therapy, pacemaker implantation, cardioneuroablation

Abstract

Introduction

Syncope is a sudden, brief loss of consciousness with rapid spontaneous recovery, caused by transient global cerebral hypoperfusion. Among various causes of syncope, the most common are reflex mechanisms, particularly vasovagal syncope (VVS) [1]. At present, the tilt test is the most widely used non-invasive method for testing the cardiac autonomic nervous system. Tilt test results are verified using the modern VASIS classification, which distinguishes three types of vasovagal syncope.

Aim

The aim of this study was to determine the role of the tilt test in assessing the cardiac autonomic nervous system and its influence on the selection of treatment strategies for patients with vasovagal syncope.

Materials and Methods

A retrospective analysis was conducted on data from 40 patients who presented to the Amosov National Institute of Cardiovascular Surgery with recurrent syncope and had a positive tilt test result. Among those examined were 30 men and 10 women, with a mean age of 37.8 ± 11.6 years (with an age range of 15-69 years). The tilt test was performed according to the classical Italian protocol. Following the test and confirmation of vasovagal syncope, each patient was assigned an appropriate treatment strategy – ranging from conservative management to invasive interventions.

Results.

All 40 patients had a positive tilt test result, confirming the vasovagal origin of syncope. This high rate of positive responses likely reflects careful preselection of candidates for potential invasive treatment. Syncope occurred in 36 patients (90 %) during the nitroglycerin provocation phase and in 4 patients (10 %) during the passive tilt phase. The mean time to syncope in the passive tilt phase was 10.8 ± 2.1 minutes (range: 8-15 minutes), while in the nitroglycerin phase it was 4.2 ± 2.3 minutes (range: 1-13 minutes). A cardioinhibitory type was identified in 24 patients (60 %), a mixed type in 11 (28 %), and a vasodepressor type in 5 (12 %).

Treatment strategies were determined jointly with the patients. Fourteen individuals with recurrent syncope and a pronounced vagal component underwent catheter ablation of parasympathetic ganglionated plexi, with no procedural complications and complete resolution of vagally mediated sinus node dysfunction. Another 10 with the cardioinhibitory type opted for conservative therapy. Among those with the mixed type, six underwent cardioneuroablation, while the remaining five were managed conservatively. Invasive interventions for the vasodepressor type remain uncommon [10,12], and these patients were treated conservatively.

Conclusions

The tilt test plays a crucial role in diagnosing vasovagal syncope by assessing the cardiac autonomic nervous system. Accurate classification of the vasovagal syncope type using the VASIS classification directly influences subsequent treatment decisions. According to numerous contemporary studies, invasive treatments demonstrate the greatest effectiveness in patients with the cardioinhibitory type of vasovagal syncope.

References

  1. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG; ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 Jun 1;39(21):1883-948. https://doi.org/10.1093/eurheartj/ehy037
  2. Glikson M, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021 Sep 14;42(35):3427–3520. https://doi.org/10.1093/eurheartj/ehab364
  3. Udyavar A, Shenthar J, Naik AM, Khanra D, Ramalingam V, Singhal R, Choudhary D, Gupta PN, Rao BH, Mehrotra S, Arora V, Kathuria S, Suri P, Benditt D, Sutton R. A contemporary review of the head-up tilt test: Utility and limitations. Indian Heart J. 2025 Apr 2:S0019-4832(25)00060-4. https://doi.org/10.1016/j.ihj.2025.03.014
  4. Li L, Po S, Yao Y. Cardioneuroablation for Treating Vasovagal Syncope: Current Status and Future Directions. Arrhythm Electrophysiol Rev. 2023 Jun 9;12:e18. https://doi.org/10.15420/aer.2023.02
  5. Pachon JC, Pachon EI, Pachon JC, Lobo TJ, Pachon MZ, Vargas RN, Jatene AD. Cardioneuroablation – new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation. Europace. 2005 Jan;7(1):1-13. https://doi.org/10.1016/j.eupc.2004.10.003
  6. Sheldon R, Raj SR, Rose MS, Morillo CA, Krahn AD, Medina E, Talajic M, Kus T, Seifer CM, Lelonek M, Klingenheben T, Parkash R, Ritchie D, McRae M; POST 2 Investigators. Fludrocortisone for the Prevention of Vasovagal Syncope: A Randomized, Placebo-Controlled Trial. J Am Coll Cardiol. 2016 Jul 5;68(1):1-9. https://doi.org/10.1016/j.jacc.2016.04.030
  7. Gampa A, Upadhyay GA. Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge. J Innov Card Rhythm Manag. 2018 Jul 15;9(7):3221-3231. https://doi.org/10.19102/icrm.2018.090702
  8. Schroeder C, Tank J, Heusser K, Diedrich A, Luft FC, Jordan J. Physiological phenomenology of neurally-mediated syncope with management implications. PLoS One. 2011;6(10):e26489. https://doi.org/10.1371/journal.pone.0026489
  9. Tymoshenko DA, et al. Cardioneuroablation for the treatment of vasovagal syncope. UJC. 2025 Apr 28;32(2):67-74. https://doi.org/10.31928/2664-4479-2025.2.6774
  10. Tu B, Lai ZH, Chen AY, Weng ZY, Cai SM, Zhang ZX, Zhou LK, Zheng LH, Yao Y. Effectiveness of cardioneuroablation in different subtypes of vasovagal syncope. J Geriatr Cardiol. 2024 Jun 28;21(6):651-657. https://doi.org/10.26599/1671-5411.2024.06.004
  11. Piotrowski R, Baran J, Sikorska A, Krynski T, Kulakowski P. Cardioneuroablation for Reflex Syncope: Efficacy and Effects on Autonomic Cardiac Regulation-A Prospective Randomized Trial. JACC Clin Electrophysiol. 2023 Jan;9(1):85-95. https://doi.org/10.1016/j.jacep.2022.08.011
  12. Chen Z, Li Y, Liu Y, Shen G, Xiong G, Wu B, Liu Y, Huang X, Li H, Zhou H, Xu Z, Zhang G, Tao Y, Zhang F, Lai H. Efficacy of cardioneuroablation for vasodepressor vasovagal syncope. Front Neurosci. 2025 Apr 4;19:1514513. https://doi.org/10.3389/fnins.2025.1514513
  13. Groppelli A, Russo V, Parente E, Comune A, de Lange FJ, Rivasi G, Rafanelli M, Deharo JC, Francisco-Pascual J, Maggi R, Fedorowski A, Ungar A, Parati G, Brignole M. Mechanism of syncope: role of ambulatory blood pressure monitoring and cardiovascular autonomic function assessment. Eur Heart J. 2025 Mar 1;46(9):827–835. https://doi.org/10.1093/eurheartj/ehae907
  14. Aksu T, et al. Cardioneuroablation for the treatment of reflex syncope and functional bradyarrhythmias: A Scientific Statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS) and the Latin American Heart Rhythm Society (LAHRS). Europace. 2024 Aug 3;26(8):euae206. https://doi.org/10.1093/europace/euae206
Published
2025-09-25
How to Cite
1.
Tymoshenko DA, Derkach MV, Topchii AV. Tilt Test as a Primary Non-Invasive Method for Testing Cardiac Autonomic Nervous System Function in Patients with Vasovagal Syncope. ujcvs [Internet]. 2025Sep.25 [cited 2025Oct.9];33(3):106-11. Available from: https://www.cvs.org.ua/index.php/ujcvs/article/view/763
Issue
Ukrainian Journal of Cardiovascular Surgery Vol 33 No 3 2025
Section
RHYTHM DISTURBANCES