Tilt Table Test: State of The Art

The loss of consciousness has been a subject of wonder and uncertainty in humans, and for this reason it has been the object of medical investigation since the beginning of time. Even actually, it is certainly an unresolved clinical problem. Many centuries ago, complicated exorcisms and remedies were used on these unfortunate patients, who upon regaining consciousness would find themselves soaked in miraculous liquids, ingesting curative potions, and often on the way to be burned accused of being possessed. In the seventeen century, physicians began to relate loss of consciousness and haemodinamic changes. William Harvey was perhaps the first to describe a circulatory response (vasovagal reaction) during a phlebotomy in the year 1628: “...Yet it fear or any other cause, or something do intervene through passion of the mind, so that the heart do beat more faintly, the blood will be no means pass through but drop after drop...”1. During the nineteenth century, loss of consciousness was the object of studies and research, and the vagally mediated cardioinhibition, as a primary cause, was noted by Foster who proposed that profound bradycardia diminished cerebral perfusion to a level inadequate to maintain consciousness2. At this time, it was reported the first use of the tilt-table test3. Commonly referred to as fainting or loss of consciousness, from last century the preferred medical term is syncope, which itself is derived from the Greek term “syncoptein” meaning “to cut short”. Syncope is defined as the sudden loss of consciousness and postural tone with spontaneous recovery. In 1907, Gowers was the first person to use the term vasovagal syncope4. In 1918 was published the work in which Cotton and Lewis described for the first time the clinical characteristics that are still used today to recognize the syncopal reaction5. However, it was not till 1932 when Lewis described this reaction as being characterized by a combination of bradycardia, hypotension, and syncope, and he coined the term vasovagal syncope for the first time6. From the first studies with patients suffering loss of consciousness, it was observed that they all suffered a haemodynamic collapse which, though poorly understood initially, was analyzed with the diagnostic methods of the time period. In the past, those patients with recurrent syncopes were often subjected to a long, tedious, expensive, and all too often fruitless routine series of tests aimed at disclosing a potential aetiology. It was not until 1957 that one of the pioneering works on the use of the tilt-table test on such patients was published. In this work with university students, Weissler et al. tilted the individuals to 60o and observed 20% positive (abnormal) results. They induced syncope in others by oral administration of sodium nitrate