Tilt table test

I'm visiting psychiatrists for the N-th time. But this time it's a good one. She agreed with me that my fatigue is probably due to some undiagnosed physical condition. I asked her about the tilt table test but she had no idea what that is. (that is, not because she's a bad doctor, but she doesn't speak English and I didn't know how it is in Bulgarian). So I asked another doc and she said me - oh no, this is not for you, this is test for syncope, for people with heart problems. So my question is do you agree with this. My heart goes a lot faster from minimal activities. Is this not an evidence for some abnormality. And another question - I'm actually afraid because some people here complained they got PEM from TTT.

 

The tilt table test is also used to diagnose POTS.

Do you have symptoms consistent with POTS?

From https://www.nhs.uk/conditions/postural-tachycardia-syndrome/

 

I didn’t have bad PEM from the tilt test, more than I would expect from the trip to rue hospital, but I was not given the traditional tilt test, it was a stand test from lying down, I was connected to machines to measure all kind of things. The test did not continue once they had enough data so I did not have to pass out. I think it was a more humane method than the standard tilt test.

I was found to have POTS. I agree with people above. If you can gather some heart rate and blood pressure readings and write what you were doing at the time, a doctor will be more likely to listen.

 

I would say it is an indication of being unwell but a very non-specific indication. Being unwell for a hundred reasons will lead to a fast heart rate with minimal activity.

I would not personally think a tilt table test would be helpful here. If slight stimuli make your heart go faster then a tilt table test might also make your heart go faster. But there would be no reason to think that was some specific reaction to posture because you get the same thing with other stimuli.

In a sense a positive tilt table test defines POT - postural orthostatic tachycardia - but whether that indicates POTS is a much more difficult issue. POTS is supposed to be the combination of POT with symptoms of the sort that occur in ME. If you already have those symptoms all that the tilt table test will show is that there is POT. It will not show that any of your symptoms are due to a syndrome called POTS. As I understand it a positive tilt table test can occur in normal people anyway and I suspect it will occur in people ill for other reasons.

I don't think a positive tilt table test is an indication of any specific autonomic system failure. The tachycardia, if anything, indicates that the autonomic system is responding sensitively to something.

 

I think the case for undergoing tilt-table testing and pursuing a POTS diagnosis is a utilitarian one: if positive, it affords you access to medications for orthostatic intolerance and postural tachycardia, if they're high on the list of bothersome symptoms. It's unlikely that anyone would initiate (say) ivabradine or midodrine empirically, solely on the basis of patient-reported ME symptoms, without a TTT.

The other aspect is that a minority of patients experience a marked yet transient elevation of plasma catecholamines on tilt: the so-called `hyperadrenergic' subtype of POTS (when I was given this test, at NHNN, it was positive) which will result in being offered additional treatment options such as clonidine. Whether or not this subtyping is relevant - or even to what extent this feature might occur in the healthy population - are open questions; I really do wish the will and funding to perform the research was there.

The tilt testing did cause me a PEM flare for a week or so afterwards.

 

Would agree on all the advice above of HR monitoring on a stand test at home, before pursuing a referral.
I had done it 3 times at home and the consultant was interested to have the figures and looked carefully at them.
He also confirmed with a short stand test in clinic before referring me for a TTT.

When I had finished my TTT I asked the staff how many people they saw who fitted the POTS criteria (UK NHS, catchment area around 1 million).
The physiologist said they had a quite lot of referrals of people who thought they had POTS but didn't, and thought they saw 1-2 a year who had a positive test.
I was the first person the attending doctor had seen with it.

On the PEM side I was quite bad, kicked in 48 hours after, but no permanent deterioration.
But I had to make my own way by public transport to the next city for the appointment, a friend was able to pick me up after and bring me home.

I had also had a clinic appt at the same hospital the previous week, and was moving out of job related accommodation 3 weeks after the test, so was under a lot of pressure anyway.

As said above, it also depends what you want it for.
I wanted it as evidence for work, and the possibility of medication to see if it helped.

But because of the wait for the appointment my sick pay had already run out, and I was moving to an area with no specialists so didn't want to start anything during a house move, with no-one supervising.

 

A tilt result positive for POTS combined with other relevant clinical symptoms should also lead to further investigations.

Presumably in an ideal world these would be performed regardless, but my experience has been that you need the extra weight of evidence to justify further testing. Not to mention most of the related issues aren't appreciated outside of specialist centers. Skin biopsy for Small Fibre Neuropathy in relation to POTS is a good example.

 

Page 18 of the Overview for the Canadian Consensus Criteria (CCC), under the subheading: "Chronic orthostatic intolerance", says "Use tilt table test or monitor the pulse and blood pressure while standing. Note: This monitoring must be done with caution and someone standing beside the patient." (my bolding)
https://www.mefmaction.com/images/stories/Overviews/ME-Overview.pdf



The CCC Overview also references this study re impedance cardiograph testing:

Am J Med Sci. 2003 Aug;326(2):55-60.
Abnormal impedance cardiography predicts symptom severity in chronic fatigue syndrome.
Peckerman A1, LaManca JJ, Dahl KA, Chemitiganti R, Qureishi B, Natelson BH.
Author information
1
Department of Neurosciences, CFS Cooperative Research Center, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA. apeckerm@njneuromed.org
Abstract
BACKGROUND:
Findings indicative of a problem with circulation have been reported in patients with chronic fatigue syndrome (CFS). We examined this possibility by measuring the patient's cardiac output and assessing its relation to presenting symptoms.

METHODS:
Impedance cardiography and symptom data were collected from 38 patients with CFS grouped into cases with severe (n = 18) and less severe (n = 20) illness and compared with those from 27 matched, sedentary control subjects.

RESULTS:
The patients with severe CFS had significantly lower stroke volume and cardiac output than the controls and less ill patients. Postexertional fatigue and flu-like symptoms of infection differentiated the patients with severe CFS from those with less severe CFS (88.5% concordance) and were predictive (R2 = 0.46, P < 0.0002) of lower cardiac output. In contrast, neuropsychiatric symptoms showed no specific association with cardiac output.

CONCLUSIONS:
These results provide a preliminary indication of reduced circulation in patients with severe CFS. Further research is needed to confirm this finding and to define its clinical implications and pathogenetic mechanisms.https://www.ncbi.nlm.nih.gov/pubmed/12920435



Page one of the Overview, under "Natural Course" says: " Objective postural cardiac output abnormalities correlate with symptoms severity and reactive exhaustion."

I understand that the impedance cardiograph can indicate cardiac output. However, I believe the usual way to do this test is just supine.

Some researchers have done this test both supine, and then compare the patient's results to when they are standing while using the impedance cardiograph.

The comparison between supine results and standing may be quite revealing of cardiac function.

 

I have severe ME and symptoms of POT - heart rate raised over 30 bpm within 10 minutes of standing. I was referred for a TTT by my GP and it was just as well. A TTT usually lasts about 20 minutes plus, but the consultant who carried out mine halted it at 10 minutes because the monitoring showed that not only was my HR banging away at over 130 bpm within seconds of moving up from the horizontal, but my blood pressure was alarmingly high, as 199/140 - high enough to cause a stroke or heart attack and he was worried the test itself could provoke this. I've since been put on to hypertension meds to help with keeping my BP down when I'm upright (even just sitting up can cause it to rise), which, I have to admit, really annoys me because my BP is bang on normal for my age just as long as I'm lying down. I'm only hypertensive if I'm upright! But I'd never have known it was being pushed so high if I hadn't had the TTT done, and I could have died from a cardiovascular event without ever knowing I was at risk. Low BP runs in my family so as I'd always measured mine lying down and everything you read about POTS and orthostatic intolerance always talks about falling BP, never raised BP, I never even considered that mine might not be doing the same. And it could have killed me.

I did have PEM as a result of the test but nothing out of the ordinary, for me at least, and it only lasted for a couple of weeks. It was well worth it though, otherwise I'd never have known that simply from being upright I was risking a stroke or a heart attack, and I'd never have had meds to help stop it happening.

 

A basic standing test may be okay for diagnosing POTS. But what about other forms of orthostatic intolerance?

From what I've read the tilt table test and/or the NASA lean test are better at detecting certain problems like Neurally Mediated Hypotension (NMH).

Several different names have been used for NMH so please use whatever name you want. I'm talking about the situation where the heart rate does not increase enough in the first 10 minutes for a POTS diagnosis but symptoms (dizziness, nausea, etc) start in 5-10 minutes. And then sometime after 20-40 minutes on the tilt table test the patient has a sudden drop in blood pressure and faints.

It's hard to tell whether this situation applies to the original poster based on the description of symptoms given. But others reading this thread might find it useful.

 

I think a TTT would only be useful if done by someone who understands it’s use in our condition. If done by someone who only knows it’s usefulness for syncope, you end up with a “normal” result if you don’t pass out even though you may have lots of other symptoms or abnormal physiological responses. If they don’t know how to interpret your response it’s often ignored.

 

I had a positive tilt table test. It was very unpleasant at the time (my heart stopped) but the PEM was no worse than any other kind of hospital appointment. As long as you are properly monitored, I think it is worth having. IMO all ME patients should have one and I think the opinion of your other doc is probably due to a reluctance to do any testing in ME patients.

 

I found its a good way to scare nurses and GPs, I had a 24hr BP monitor hang around 180/100 most of the evening, despite being relaxed on the couch. It hit 220/140 when walking from the car park to the waiting room the next morning to hand it back. I got a shitty response from the nurse when I asked her to check the accuracy, her attitude changed rather quickly when she saw why...

The diagnostic criteria for POTS dictates that there should not be a significant fall in blood pressure upon standing, if there is a fall Orthostatic Hypotension is often a better fit instead. Having a raised BP however is very common and expected if your POTS is more hyperadrenergic dominant.

Often with better controlled POTS and lower sympathetic tone you will find that BP control becomes more normal, anti-hypertensives aren't always necessary and can make things worse. My BP became much more normal after treating POTS, without resorting to anti-hypertensives.

 

I did the home testing first, presented the results to GP then did the TTT in hospital.

I’ve noticed recently, that my PoTS doesn’t seem to cause PEM afterwards; instead I tend to get PoTS either during PEM from exertion, or before the PEM has began.

last time I walked a mile, my heart rate increased normally for walking... then about an hour after I’d finished and was sitting upright resting and nodding off, this is when the PoTS kicked in.

I felt really relaxed even though exhausted but my heart monitor kept alerting me to the tachycardia as I was nodding off/dozing.