Tilt Table Testing

Number: 0299

Policy

Aetna considers tilt table testing, alone or in combination with administration of provocative agents (e.g., isoproterenol), medically necessary for the evaluation of members with recurrent unexplained syncope who have an inconclusive history and physical examination, as well as negative non-invasive tests of cardiac structure and function.

Aetna considers tilt table testing, alone or in combination with administration of provocative agents (e.g., isoproterenol), medically necessary as part of a diagnostic workup for individual with suspected postural orthostatic tachycardia syndrome (POTS). 

Aetna considers the use of tilt table testing experimental and investigational for all other indications, including any of the following (not an all-inclusive list) because there is little support in the peer-reviewed medical literature for tilt table testing for these indications:

• Determining the effectiveness of medications in treating recurrent unexplained syncope; or
• Diagnosing joint hypermobility syndrome; or
• Differential diagnosis of parkinsonian syndromes (e.g., Parkinson's disease, multiple system atrophy and progressive supranuclear palsy); or
• Evaluating dizziness and vertigo; or
• Evaluating post-concussion syndrome; or
• Guiding surgical decision-making as well as predicting the clinical response to surgical decompression of Chiari type I-malformation (Chiari drop attacks); or
• Identifying members with chronic fatigue syndrome and/or evaluating treatment effectiveness of this condition.

See also CPB 0369 - Chronic Fatigue Syndrome.

Background

There is sufficient evidence that tilt table testing, with or without isoproterenol, is safe and effective as a diagnostic tool for the evaluation of patients with recurrent unexplained syncope.  The reported sensitivity, specificity, and reproducibility of tilt table testing ranged from 65 to 87 %, 55 to 96 %, and 71 to 88 %, respectively.  This procedure helps to identify a largely benign disorder and, indirectly, exclude other possibly life-threatening conditions.  Tilt table testing performed early in the evaluation may obviate extensive and expensive tests such as intra-cardiac electrophysiological studies, CAT scan, and MRI of the brain.  In contrast, there is insufficient evidence that tilt table testing following intravenous infusion of metoprolol can accurately predict the effectiveness of oral metoprolol therapy in treating patients with recurrent unexplained syncope.  This procedure has not been shown to provide any additional information than would have been obtained from a trial of oral therapy.

There is inadequate evidence of the effectiveness of tilt-table testing for identifying chronic fatigue syndrome (CFS) patients who would respond to medications to increase their blood pressure.  Several case series have shown that patients with known CFS frequently have abnormal responses to tilt-table testing, and CFS patients in these series also frequently appear to respond to anti-hypotensive medications commonly used in patients with neurally mediated hypotension.  These case studies fail to demonstrate, however, any value of tilt-table testing in distinguishing CFS patients that would respond to these medications from those who would not.

Straus and colleagues (2009) stated that Chiari I malformation (CM1) is characterized by impaired cerebrospinal fluid flow through the foramen magnum.  Dysfunctional autonomic cardiovascular regulation may result in syncope, which may be the primary presenting symptom of CM1 (a syndrome termed Chiari drop attack).  It has been postulated that Chiari drop attack is secondary to dysautonomia caused by hind-brain compression.  These researchers studied patients with Chiari drop attacks who had negative work-ups for cardiac syncope, followed by tilt table testing and subsequent surgical decompression.  They reported test results and clinical outcomes following CM1 decompression.  A total of 10 patients met the inclusion criteria: 5 patients had positive and 5 negative tilt table tests.  Following decompression, 7 had symptomatic improvement or resolution and 3 failed to improve.  The sensitivity and specificity of the tilt table test for detecting clinical improvement with surgical decompression was 43 % and 33 %, respectively.  Tilt table testing had 40 % accuracy in predicting clinical response to decompression.  The authors concluded that in this short series, surgical decompression of CM1 has a high success rate (70 %) for patients with Chiari drop attacks.  Moreover, tilt table testing has poor predictive value in judging the clinical response to surgical decompression and is not a useful test to guide surgical decision-making.

Uno and colleagues (2009) noted that although it is well known that autonomic dysfunction in obstructive sleep apnea syndrome (OSAS) is associated with hypertension, its relationship to hypotension and orthostatic dysregulation is still unclear.  These investigators examined the response of blood pressure (BP) and cardiovascular autonomic function to head-up tilt (HUT) test in patients with OSAS.  In this study, a total of 14 patients (mean age of 65 +/- 2 years old, male/female: 11/3) with diagnosed OSAS by over-night polysomnography and 84 healthy subjects (mean age of 62 +/- 1 years old, male/female: 46/38) underwent HUT test (from 5 to 10 mins at 45 degrees).  Autonomic functions were evaluated by spectrum analysis of BP and heart rate variability.  In healthy subjects, systolic BP was unchanged by HUT test due to the enhancement of sympathetic nerve activity and the inhibition of parasympathetic nerve activity.  In contrast, autonomic responses were unchanged and systolic BP tended to be decreased by HUT test in OSAS patients.  The authors concluded that the findings of this study suggested that baroreflex function is impaired in patients with OSAS.  Furthermore, HUT test with spectrum analysis may be useful to evaluate autonomic functions in OSAS patients.

1. the last 2 mins of the supine period;
2. the 15 secs of tilting movement (TM); and
3. the 1st (TT1) and 2nd (TT2) min of HUT. 

1. PD (n = 19),
2. MSA (n = 14),and
3. uncertain (n = 14). 

1. R-R interval variations during deep breathing,
2. heart rate changes with the Valsalva maneuvre,
3. tilt table testing,
4. the sudomotor axon reflex test, and
5. thermoregulatory sweat testing. 

Reimann et al (2010) stated that differential diagnosis of parkinsonian syndromes is a major challenge in movement disorders.  Dysautonomia is a common feature but may vary in clinical severity and onset.  These investigators attempted to find a pattern of autonomic abnormalities discriminative for patients with different parkinsonian syndromes.  The cross-sectional study included 38 patients with MSA, 32 patients with progressive supranuclear palsy (PSP), 26 patients with idiopathic PD (IPD), and 27 age-matched healthy controls.  Autonomic symptoms were evaluated by a standardized questionnaire.  The performance of patients and controls was compared on 5 autonomic function tests:

1. deep breathing,
2. Valsalva maneuvre,
3. tilt-table testing,
4. sympathetic skin response,
5.  pupillography, as well as 24-hr ambulatory BP monitoring (ABPM). 

Disease severity was significantly lower in IPD than PSP and MSA.  Except for pupillography, none of the laboratory autonomic tests distinguished one patient group from the other alone or in combination.  The same was observed on the questionnaire.  Receiver operating characteristic curve revealed discriminating performance of pupil diameter in darkness and nocturnal BP change.  The composite score of urogenital and vasomotor domains significantly distinguished MSA from IPD patients but not from PSP.  These findings supported the observation that even mild IPD is frequently indistinguishable from more severe MSA and PSP.  Thus, clinical combination of motor and non-motor symptoms does not exclusively point at MSA.  Pupillography, ABPM and the questionnaire may assist in delineating the 3 syndromes when applied in combination.

Postural orthostatic tachycardia syndrome (POTS), also known as postural tachycardia syndrome, is a type of orthostatic intolerance that is characterized by excessive tachycardia and decreased cerebral blood flow in the upright position.  This can result in significant symptoms of dizziness and light-headedness that can eventually lead to syncope.  Symptoms of POTS include light-headedness, visual blurring, palpitations and weakness on assuming an upright posture; these symptoms are relieved by resuming a supine posture.  Tilt table testing has been used to aid in the diagnosis of POTS. 

An UpToDate review on “Postural tachycardia syndrome” (Freeman and Kaufmann, 2012) states that: “The diagnosis of POTS is established from the history and head-up tilt testing which demonstrates a heart rate increase of >30 bpm over baseline or to >120 bpm.  Dehydration, prolonged bedrest, medications, and other dysautonomias should be excluded as etiologies”.

Grubb et al (1997) stated that HUT testing has emerged as an accepted modality for identifying an individual's predisposition to episodes of autonomically mediated hypotension and bradycardia that are sufficiently profound so that transient loss of consciousness ensues (neuro-cardiogenic syncope [NCS]).  However it has also become apparent that less dramatic falls in BP, while not sufficient to cause full syncope, may produce symptoms such as near syncope, vertigo, dizziness, and transient ischemia attack-like episodes.  These investigators have identified a subgroup of individuals with a mild form of autonomic dysfunction with symptoms of postural tachycardia and lightheadedness, disabling fatigue, exercise intolerance, dizziness, and near syncope.  During baseline tilt table testing these patients demonstrated a HR increase of greater than or equal to 30 beats per min [bpm] (or a maximum HR of 120 bpm) within the first 10 mins upright (unassociated with profound hypotension), which reproduced their symptom complex.  In addition these patients exhibited an exaggerated response to isoproterenol infusions.  Similar observations have been made by others who have dubbed this entity the POTS.  The authors concluded that POTS represents a mild (and potentially treatable) from of autonomic dysfunction that can be readily diagnosed during HUT testing.

1. autonomic function tests (HUT test),
2. oscillations at respiratory and non-respiratory frequencies (0.01 to 0.09 Hz) in R-R interval and BP (Wigner distribution), and
3. deterministic component (re-scaled range analysis). 

1. orthostatic HR during the 1st minute of the HUT test,
2. autonomic deficit (adrenergic autonomic score),
3. loss of spectral powers in R-R interval during the HUT test at the 5th minute, and
4. severity of orthostatic dizziness, fatigue, palpitations, and shortness of breath. 

Lamarre-Cliche and Cusson (2001) stated that the HUT test is used primarily for the investigation of orthostatic symptoms.  Although this test is frequently the gold standard for the evaluation of NCS, dysautonomia and POTS, there is a debate over its diagnostic value and method.  The authors reviewed the physiologic basis of the HUT test, the method, patterns of response, indications and contraindications, and diagnostic validity.  They concluded that despite its limitations, the HUT test is useful in patients with a variety of clinical manifestations induced by orthostatism.  It is most useful in documenting objective measures of orthostatic hypertension (OH) that cannot be obtained in a clinical setting.

In a prospective study, Singer et al (2002) examined if an intrinsic sinus node abnormality is involved in the pathophysiology of POTS.  These researchers compared the relationship between P-wave axis (PWA) and HR in 11 healthy controls and 14 patients with POTS by obtaining 12-lead electrocardiographic recordings during supine rest and during gradual HUT test.  The HR of controls was titrated with isoproterenol infusion to match the HR of patients.  The PWA was compared at different HR levels, and the relationship between HR and PWA was assessed for patients and controls.  Primary end points were the PWA-HR relationship in healthy controls, comparison of these data with data from patients with POTS as a group, and identification of a possible subgroup of patients with POTS with irregular PWA-HR relationship.  The PWA increased with increasing HR following a similar logarithmic trend-line in both groups.  The PWA of patients was significantly lower at the lowest comparable HR level, but not different at faster HR levels.  Three patients (21 %) had a clearly abnormal HR-PWA relationship with substantial shift toward lower PWA.  The authors concluded that these findings supported the hypothesis of a primary sinus node abnormality in a subset of patients with POTS.

Winker et al (2005) evaluated the role of the Schellong test (ST) in forms of orthostatic dysregulation in comparison with the tilt-table test (TT).  A total of 67 young males (mean age of 22 +/- 4 years) from the military service, representing 2 different cohorts, were examined by ST and TT, which served as gold standard.  Overall, 32 of the 67 subjects were asymptomatic while 35 had sought medical advice because of orthostatic complaints.  The subjects subsequently were classified into 4 categories according to the TT:

1. normal TT,
2. OH,
3. POTS, and
4. NCS. 

Chi-square test was used to calculate the sensitivity and specificity of ST in detecting forms of orthostatic dysregulation (OH, POTS and NCS).  In total, TT detected 23 recruits with POTS, 16 with NCS and 2 with OH.  Out of the 32 asymptomatic subjects only 1 was diagnosed having POTS by TT and ST, the rest had a normal ST and TT.  For detecting POTS, ST sensitivity was 61 % and specificity was 100 % compared with TT.  For detecting NCS, ST sensitivity was 31 % and specificity 100 % compared with the reference test, the TT.  The data concerning OH could not be analyzed because of the small number of cases.  The authors concluded that these findings indicated that ST can be used in first line in the diagnosis of patients with orthostatic symptoms by the medical practitioner.  If the ST is normal, further examination by TT is indispensable, because sensitivity of ST concerning POTS and NCS is relatively low.

Qingyou et al (2008) stated that OI is a common clinical manifestation in clinical pediatrics.  The HUT test is considered the standard of orthostatic assessment, but the physiologic neuro-circulatory profile during HUT has not been fully realized in children with OI.  The present study, therefore, was designed to investigate the physiologic patterns that occur during HUT in children with OI.  A total 90 children (56 girls; mean age of 11.6 +/- 2.3 years) with OI underwent HUT test under quiet circumstances; BP and HR were monitored simultaneously.  A total of 49 children with OI (54.4 %) had vaso-vagal response with HUT testing; 33 (36.7 %), vasodepressor response; 6 (6.7 %), cardio-inhibitory response; and 10 (11.1 %), mixed response.  Twenty-eight children (31.1 %) had POTS; 1 (1.1 %), OH; and 12 (13.3 %), normal physiologic response.  Patterns of cerebral syncope response and chronotropic incompetence were not observed.  The authors concluded that classical vaso-vagal response was the major physiologic pattern seen in children with OI during HUT testing, and POTS response ranked second.

In a case-control study, Carew and colleagues (2009) defined the optimal duration of TT for the assessment of patients with suspected POTS.  Cases were identified retrospectively from a database of patients referred with OI.  All met the diagnostic criteria for POTS.  Controls were enrolled prospectively.  All subjects underwent tilting to 70 degrees for 40 mins if tolerated.  Continuous monitoring was provided by a Finometer.  Analysis of responses to TT was performed on 28 cases and 28 controls.  The mean age in the case group was 23.6 years and in the control group was 26.2 years.  The majority was female in both groups (cases = 4 females and 3 males, controls = 2 females and 1 male).  All cases met the criteria for POTS within 7 mins of orthostasis.  No controls demonstrated a sustained tachycardia.  The prevalence of vaso-vagal syncope (VVS) was 36 % in cases versus 7 % in controls (p = 0.02) and 25 % in the remaining patients (n = 233) on the OI database (p = 0.259).  The authors concluded that a 10-min TT will diagnose POTS in the majority of patients.  It will not, however, be sufficient to identify the overlap that exists between POTS and VVS.  The optimal duration of TT in patients suspected of POTS is 40 mins.

Singer et al (2012) examined if the use of adult HR criteria is appropriate for diagnosing OI POTS in children and adolescents, and established normative data and diagnostic criteria for pediatric OI and POTS.  A total of 106 normal controls aged 8 to 19 years (mean age of 14.5 +/- 3.3 years) underwent standardized autonomic testing, including 5 mins of 70-degree HUT testing.  The orthostatic HR increment and absolute orthostatic HR were assessed and retrospectively compared with values in 654 pediatric patients of similar age (mean age of 15.5 +/- 2.3 years) who were referred to our Clinical Autonomic Laboratory with symptoms of OI.  The HR increment was mildly higher in patients referred for OI/POTS, but there was considerable overlap between the patient and control groups.  Some 42 % of the normal controls had an HR increment of greater than or equal to 30 bpm.  The 95th percentile for the orthostatic HR increment in the normal controls was 42.9 bpm.  There was a greater and more consistent difference in absolute orthostatic HR between the 2 groups, although there was still considerable overlap.  The authors concluded that the diagnostic criteria for OI and POTS in adults are unsuitable for children and adolescents.  Based on the normative data from this study, the authors proposed new criteria for the diagnosis of OI and POTS in children and adolescents.

UpToDate reviews on “Evaluation of dizziness in children and adolescents” (Walls and Teach, 2013) and “Approach to the patient with vertigo” (Furman and Barton, 2013) do not mention the use of tilt table testing as a management tool.

Post-Concussion Syndrome

Heyer et al (2016) examined HUT signs of autonomic dysfunction in a cohort of youth with persistent post-concussion symptoms (PCSs) that include light-headedness and to correlate repeat tilt table results with symptom improvements for those patients found to have POTS on initial testing.  A total of 34 patients (13 to 18 years of age) with persistent PCSs participated in this study.  All patients underwent at least 1 tilt table test.  The PCS Interview (PCS-I) and patient ratings of light-headedness and vertigo were used to measure symptom burden.  Patients found to have POTS were asked to repeat tilt table testing when PCSs improved or 3 to 6 months after the initial test if symptoms persisted.  Overall, 24 of the 34 (70.6 %) patients had abnormal tilt table results with patients categorized as normal (n = 10), isolated syncope (n = 10), and POTS (n = 14).  Patients with POTS had higher PCS-I scores than normal patients (p < 0.001) and higher ratings of light-headedness than both normal patients (p = 0.015) and syncope patients (p = 0.04); 12 POTS patients underwent repeat tilt table testing, and 9 of 12 (75 %) no longer met POTS diagnostic criteria.  All patients with resolution of POTS had corresponding improvements in PCSs, including light-headedness and vertigo.  The authors concluded that the findings of this study demonstrated a high rate of tilt table abnormalities among youth with persistent PCSs.  Several patients with POTS had normalization of tilt table testing when PCSs improved.  They stated that these findings warrant further research of autonomic dysfunction related to concussion.

Furthermore, an UpToDate review on “Postconcussion syndrome’ (Evans, 2016) does not mention tilt table testing as a management tool.

Guidance of Pacing Therapy for Reflex Syncope

Furukawa (2017) stated that the tilt table test (TTT) is a method used for the management of reflex syncope.  However, the TTT is incomplete and has several problems.  The TTT is unsuitable for all syncopal patients.  Several questions on this technology remain unclear: When should the TTT be used; for which types of patients TTT should be performed; and does the TTT provide useful information to guide indication for pacing therapy for reflex syncope.  The answers to these questions appear in recent reports from 2 guidelines published by the European Society of Cardiology and the Japan Circulation Society.  The indications for TTT do not apply to all syncopal patients, but selected patients.  For patients with low risks and rare syncopal events, the TTT is not necessary, even when diagnoses are unconfirmed.  The TTT is used not only for diagnosis of reflex syncope, but also for many clinical management of several conditions (i.e., exclusion of cardiac syncope).  The author stated that positive TTT results cannot predict the effects of pacing therapy for reflex syncope; pacing therapy should be administered based on documented electrocardiograms, TTT results (negative or positive), and other findings.

Abbreviated Tilt Table Testing for Diagnosing Postural Tachycardia Syndrome in Adults with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

van Campen and colleagues (2018) noted that orthostatic intolerance is common among individuals with myalgic encephalomyelitis (ME) / CFS.  In some ME/CFS case definitions, orthostatic intolerance is considered a core feature of the disorder.  Some studies have employed tilt table tests lasting 2 to 5 mins to diagnose one common form of orthostatic intolerance, POTS.  These investigators examined the diagnostic yield of abbreviated durations of tilt table testing in adults meeting criteria for ME/CFS, and identified the proportion with POTS misdiagnosed using testing of less than 10 mins.  Eligible participants were consecutive individuals satisfying study criteria for ME/CFS and POTS evaluated at the Stichting CardioZorg (SCZ, Hoofddorp, NL) between November 2012 and August 2018.  Individuals being treated with medications commonly used to manage orthostatic intolerance were excluded.  Head-up tilt table testing involved 15 mins of supine posture then 20 mins at 70 degrees upright.  Only the data from the first 10-min upright were used.  POTS was defined as an increase in HR during a maximum of 10 mins of upright tilt of at least 30 beats/min (bpm), in the absence of either classical or delayed orthostatic hypotension.  These investigators measured the time until HR criteria for POTS were reached using survival curves, and compared survival curves between subgroups divided by age, sex, disease duration, and degree of hypocapnia during the test.  Of 627 individuals with ME/CFS evaluated during the study period, 155 met criteria for POTS.  The median time to reaching HR criteria for POTS was 3 mins.  A 2-minute tilt table test would miss 55 % (95 % confidence interval [CI]: 48 to 63 %) of those meeting POTS criteria over the course of 10-min upright.  The median time to reaching HR criteria for POTS did not differ by sex, age, duration of ME/CFS, or hypocapnia during tilt.  The authors concluded that abbreviated tilt table testing missed a substantial proportion of those ultimately diagnosed with POTS during a 10-min tilt table test, and should be abandoned for the clinical diagnosis and in epidemiologic studies designed to estimate the prevalence of POTS among those with ME/CFS.

Tilt Table Testing for Diagnosing Joint Hypermobility Syndrome

Joint hypermobility syndrome (JHS) is a chronic disorder that presents with arthralgia, myalgia and is periodically associated with visceral manifestations and POTS.  Patients with JHS are more likely to be diagnosed with CFS or fibromyalgia compared to the general population (Mandel et al, 2017).

In a prospective study, Adamec and colleagues (2018) examined the association of ANS abnormalities on head-up tilt table test (HUTT) with generalized joint hypermobility, expressed by Beighton score (BS).  This trial enrolled 115 consecutive patients (91 women; mean age of 34.35 ± 14.11 years) referred either for the HUTT or testing of the cardiovascular autonomic reflexes together with HUTT.  Generalized joint hypermobility was evaluated according to the BS system after which HUTT was performed.  Clinically significance was considered if BS was greater than or equal to 4.  A total of 15 patients (15.1 %) had BS greater than or equal to 4.  Results of the HUTT were normal in 58 (50.4 %) patients and in 57 (49.6 %) patient HUTT was abnormal; 15 (13.0 %) patients fulfilled criteria for orthostatic hypotension, 30 (26.1 %) for reflex syncope and 21 (18.3 %) for POTS.  Patients with pathological findings on HUTT had significantly higher BS compared to patients with normal HUTT (median of 1 versus 0, p = 0.001).  There was a significant association between participants with BS greater than or equal to 4 and pathological HUTT (χ[1] = 6.392, p = 0.011).  Results of the multi-variate regression analysis revealed that increase in the BS was associated with the increased likelihood of HUTT pathology (Exp[B] 1.44, 95 % confidence interval [CI]: 1.084 to 1.922, p = 0.012), while increase in age was associated with lower risk of HUTT pathology (Exp[B] 0.968, 95 % CI: 0.939 to 0.998, p = 0.036).  The authors concluded that there was an association between ANS abnormalities on HUTT test and generalized joint hypermobility.  The clinical significance of this association needs to be further investigated.

The British Society for Paediatric and Adolescent Rheumatology’s guidelines for “Management of Joint Hypermobility Syndrome in Children and Young People” (BSPAR, 2012) stated that “Diagnosis of POTS is not easy and though it is often done by performing a tilt table test (or standing and lying heart rate if tilt table unavailable) this not validated in children and adolescents so the results of the tilt table test have to be interpreted carefully”.

Furthermore, an UpToDate review on “Joint hypermobility syndrome” (Grahame and Hakim, 2019) does not mention tilt table testing as a management tool.

The above policy is based on the following references: