The Tilt Test

A longtime patient of Doc, a middle-aged Asian woman, came in for a checkup.She was completely fine. She did however have certain episodes from a decade ago.

She would have prodromal symptoms like sweating in the palms and feet and hazy, blurry vision. Then all of a sudden she would pass out! Whether she was sitting or standing, it would not matter, she would pass out if she incurred these particular symptoms. Non-specific beta blocker had to be prescribed for the patient. Since she was prescribed the medication she did not have another episode for almost20 years and had been Doc’s patient since.

The patient went to nationally known emergency rooms three separate times. Each time, the ER did a CT scan, blood work, and the all of the results came back negative for any abnormalities.

 Doc happened to be on call for one of those ER visits.  They stated it was not a seizure and there was no indication of cancer or other serious diseases. However, when Doc answered the phone, she had a strong inclination that it might be neurocardiogenic syncope.

To confirm this, the patient was immediately scheduled for a tilt test. This is a controversial test. Patient would be given isoproterenol in an effort to induce symptoms of passing out to confirm the diagnosis. (The tilt is gradually increased upwards, which would then induce higher blood pressure, but because of the isoproterenol, the patient’s blood pressure would decrease thereby creating fainting episodes). Isoproterenol is supposed to increase the blood pressure and heart rate but her body was reacting in a completely opposite manner.

In all their years, the cardiologists doing the tests had never seen someone react so quickly to isoproterenol.  Her beta fibers were reacting oppositely.

Cardiogenic syncope is thought to have 3 separate causes:  1) the brain; 2) the patinet's own psychology or mental state; and 3) the heart.

For the patient, it was obviosuly her heart that was the issue.