{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T23:12:43Z","timestamp":1783120363473,"version":"3.54.6"},"reference-count":33,"publisher":"Oxford University Press (OUP)","issue":"2","license":[{"start":{"date-parts":[[2022,9,5]],"date-time":"2022-09-05T00:00:00Z","timestamp":1662336000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,2,16]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:p>This review addresses tilt-testing methodology by searching the literature which reports timing of asystole and loss of consciousness (LOC). Despite the Italian protocol being the most widely adopted, its stipulations are not always followed to the letter of the European Society of Cardiology guidelines. The discrepancies permit reassessment of the incidence of asystole when tilt-down is early, impending syncope, compared with late, established LOC. Asystole is uncommon with early tilt down and diminishes with increasing age. However, if LOC is established as test-end, asystole is more common, and it is age-independent. Thus, the implications are that asystole is commonly under-diagnosed by early tilt-down. The prevalence of asystolic responses observed using the Italian protocol with a rigorous tilt down time is numerically close to that observed during spontaneous attacks by electrocardiogram loop recorder. Recently, tilt-testing has been questioned as to its validity but, in selection of pacemaker therapy in older highly symptomatic vasovagal syncope patients, the occurrence of asystole has been shown to be an effective guide for treatment. The use of head-up tilt test as an indication for cardiac pacing therapy requires pursuing the test until complete LOC. This review offers explanations for the findings and their applicability to practice. A novel interpretation is offered to explain why pacing induced earlier may combat vasodepression by raising the heart rate when sufficient blood remains in the heart.<\/jats:p>","DOI":"10.1093\/europace\/euac154","type":"journal-article","created":{"date-parts":[[2022,9,5]],"date-time":"2022-09-05T07:49:44Z","timestamp":1662364184000},"page":"263-269","source":"Crossref","is-referenced-by-count":26,"title":["Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology"],"prefix":"10.1093","volume":"25","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9227-0360","authenticated-orcid":false,"given":"Vincenzo","family":"Russo","sequence":"first","affiliation":[{"name":"Chair of Cardiology, University of the Study of Campania \u2018Luigi Vanvitelli\u2019, Ospedale Monaldi , Via Leonardo Bianchi, 80131 Napoli , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erika","family":"Parente","sequence":"additional","affiliation":[{"name":"Chair of Cardiology, University of the Study of Campania \u2018Luigi Vanvitelli\u2019, Ospedale Monaldi , Via Leonardo Bianchi, 80131 Napoli , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonella","family":"Groppelli","sequence":"additional","affiliation":[{"name":"IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital , Piazzale Brescia 2, 20149 Milan , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giulia","family":"Rivasi","sequence":"additional","affiliation":[{"name":"Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi , Largo Brambilla 3, 50139 Florence , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Tomaino","sequence":"additional","affiliation":[{"name":"Ospedale Generale Regionale , Via Lorenz B\u00f6hler, 5, 39100 Bolzano , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7327-303X","authenticated-orcid":false,"given":"Alessio","family":"Gargaro","sequence":"additional","affiliation":[{"name":"Research Clinical Unit, BIOTRONIK Italia S.p.A. , Via Alessandro Volta 16, 20093 Cologno, Monzese , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1584-7944","authenticated-orcid":false,"given":"Daniele","family":"Giacopelli","sequence":"additional","affiliation":[{"name":"Research Clinical Unit, BIOTRONIK Italia S.p.A. , Via Alessandro Volta 16, 20093 Cologno, Monzese , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8965-4523","authenticated-orcid":false,"given":"Andrea","family":"Ungar","sequence":"additional","affiliation":[{"name":"Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi , Largo Brambilla 3, 50139 Florence , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9402-7439","authenticated-orcid":false,"given":"Gianfranco","family":"Parati","sequence":"additional","affiliation":[{"name":"IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital , Piazzale Brescia 2, 20149 Milan , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Artur","family":"Fedorowski","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Karolinska Institute , Nobels v\u00e4g 6, 171 77 Solna, Stockholm , Sweden"},{"name":"Department of Medicine, Karolinska Institute , Nobels v\u00e4g 6, 171 77 Solna, Stockholm , Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5710-1094","authenticated-orcid":false,"given":"Richard","family":"Sutton","sequence":"additional","affiliation":[{"name":"National Heart and Lung Institute, Imperial College, Department of Cardiology, Hammersmith Hospital , Du Cane Road, London, W12 0HS , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J Gert","family":"van Dijk","sequence":"additional","affiliation":[{"name":"Department of Neurology, Leiden University Medical Centre , PO Box 9600, 2300RC Leiden , The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1845-5607","authenticated-orcid":false,"given":"Michele","family":"Brignole","sequence":"additional","affiliation":[{"name":"IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital , Piazzale Brescia 2, 20149 Milan , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2022,9,5]]},"reference":[{"key":"2023041817401423300_euac154-B1","doi-asserted-by":"crossref","first-page":"1654","DOI":"10.1093\/eurheartj\/ehab084","article-title":"Tilt testing remains a valuable asset","volume":"42","author":"Sutton","year":"2021","journal-title":"Eur Heart J"},{"key":"2023041817401423300_euac154-B2","doi-asserted-by":"crossref","first-page":"3427","DOI":"10.1093\/eurheartj\/ehab364","article-title":"ESC guidelines on cardiac pacing and cardiac resynchronization therapy","volume":"42","author":"Glikson","year":"2021","journal-title":"Eur Heart J"},{"key":"2023041817401423300_euac154-B3","doi-asserted-by":"crossref","first-page":"1825","DOI":"10.1136\/heartjnl-2013-304399","article-title":"Diagnosis of neurally mediated syncope at initial evaluation and with tilt table testing compared with that revealed by prolonged ECG monitoring","volume":"99","author":"Ungar","year":"2013","journal-title":"Heart"},{"key":"2023041817401423300_euac154-B4","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1007\/s10286-017-0441-7","article-title":"Vasovagal syncope with asystole: the role of cardiac pacing","volume":"27","author":"Brignole","year":"2017","journal-title":"Clin Auton Res"},{"key":"2023041817401423300_euac154-B5","doi-asserted-by":"crossref","first-page":"e43","DOI":"10.1093\/eurheartj\/ehy071","article-title":"Practical instructions for the 2018 ESC guidelines for the diagnosis and management of syncope","volume":"39","author":"Brignole","year":"2018","journal-title":"Eur Heart J"},{"key":"2023041817401423300_euac154-B6","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1016\/j.ijcard.2012.09.023","article-title":"Head-up tilt testing for diagnosing vasovagal syncope: a meta-analysis","volume":"168","author":"Forleo","year":"2013","journal-title":"Int J Cardiol"},{"key":"2023041817401423300_euac154-B7","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1053\/euhj.2001.2900","article-title":"Long-term outcome of patients with asystole induced by head-up tilt test","volume":"23","author":"Bar\u00f3n-Esquivias","year":"2002","journal-title":"Eur Heart J"},{"key":"2023041817401423300_euac154-B8","doi-asserted-by":"crossref","first-page":"901","DOI":"10.1016\/0002-8703(95)90110-8","article-title":"Diagnostic accuracy of a low-dose isoproterenol head-up tilt protocol","volume":"129","author":"Morillo","year":"1995","journal-title":"Am Heart J"},{"key":"2023041817401423300_euac154-B9","doi-asserted-by":"crossref","first-page":"1085","DOI":"10.1056\/NEJM199304153281504","article-title":"Comparison of cardiac pacing with drug therapy in the treatment of neurocardiogenic (vasovagal) syncope with bradycardia or asystole","volume":"328","author":"Sra","year":"1993","journal-title":"N Engl J Med"},{"key":"2023041817401423300_euac154-B10","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1016\/0002-9149(95)80030-V","article-title":"Relevance of asystole during head-up tilt testing","volume":"75","author":"Dhala","year":"1995","journal-title":"Am J Cardiol"},{"key":"2023041817401423300_euac154-B11","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1016\/j.biopha.2004.08.007","article-title":"Responses to tilt test in young and elderly patients with syncope of unknown origin","volume":"58","author":"Galetta","year":"2004","journal-title":"Biomed Pharmacother"},{"key":"2023041817401423300_euac154-B12","doi-asserted-by":"crossref","first-page":"973","DOI":"10.1111\/pace.12656","article-title":"Prognostic value of a very prolonged asystole during head-up tilt test","volume":"38","author":"Carvalho","year":"2013","journal-title":"Pacing Clin Electrophysiol"},{"key":"2023041817401423300_euac154-B13","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1016\/j.ijcard.2018.01.102","article-title":"Tilt testing and what you should know about it - experience with 835 consecutive patients with syncope of unknown origin","volume":"258","author":"Gemein","year":"2018","journal-title":"Int J Cardiol"},{"key":"2023041817401423300_euac154-B14","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1016\/S0002-9149(99)80079-4","article-title":"Value of head-up tilt testing potentiated with sublingual nitroglycerin to assess the origin of unexplained syncope","volume":"76","author":"Raviele","year":"1995","journal-title":"Am J Cardiol"},{"key":"2023041817401423300_euac154-B15","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1016\/j.hlc.2016.10.006","article-title":"Comparison of efficacy, pattern of response, occurrence of arrhythmias, and the tolerability of nitroglycerine and isoprenaline as provocative drugs during head-up tilt test","volume":"26","author":"Prabhu","year":"2017","journal-title":"Heart Lung Circ"},{"key":"2023041817401423300_euac154-B16","doi-asserted-by":"crossref","first-page":"1004","DOI":"10.1016\/S0735-1097(02)02967-4","article-title":"Age and hemodynamic responses to tilt testing in those with syncope of unknown origin","volume":"41","author":"Kurbaan","year":"2003","journal-title":"J Am Coll Cardiol"},{"key":"2023041817401423300_euac154-B17","doi-asserted-by":"crossref","first-page":"1592","DOI":"10.1016\/j.jacep.2017.07.006","article-title":"Temporal relationship of asystole to onset of transient loss of consciousness in tilt-induced reflex syncope","volume":"3","author":"Saal","year":"2017","journal-title":"JACC Clin Electrophysiol"},{"key":"2023041817401423300_euac154-B18","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1016\/S0002-8703(98)70268-6","article-title":"Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope","volume":"135","author":"Del Rosso","year":"1998","journal-title":"Am Heart J"},{"key":"2023041817401423300_euac154-B19","doi-asserted-by":"crossref","first-page":"1324","DOI":"10.1046\/j.1532-5415.2002.50351.x","article-title":"Usefulness and safety of shortened head-up tilt testing potentiated with sublingual glyceryl trinitrate in older patients with recurrent unexplained syncope","volume":"50","author":"Del Rosso","year":"2002","journal-title":"J Am Geriatr Soc"},{"key":"2023041817401423300_euac154-B20","doi-asserted-by":"crossref","first-page":"2605","DOI":"10.1093\/eurheartj\/ehm430","article-title":"Tilt testing potentiated with sublingual nitroglycerin in children with unexplained syncope","volume":"28","author":"Foglia-Manzillo","year":"2007","journal-title":"Eur Heart J"},{"key":"2023041817401423300_euac154-B21","doi-asserted-by":"crossref","first-page":"e19510","DOI":"10.1097\/MD.0000000000019510","article-title":"What is the optimal duration of the TILT after administration of 0.4\u200amg nitroglycerin spray?","volume":"99","author":"Glockler","year":"2020","journal-title":"Medicine (Baltimore)"},{"key":"2023041817401423300_euac154-B22","doi-asserted-by":"crossref","first-page":"1108","DOI":"10.1093\/europace\/euv262","article-title":"Tilt testing results are influenced by tilt protocol","volume":"18","author":"Zy\u015bko","year":"2016","journal-title":"Europace"},{"key":"2023041817401423300_euac154-B23","doi-asserted-by":"crossref","first-page":"e126","DOI":"10.1161\/CIRCRESAHA.120.316662","article-title":"Novel methods for quantification of vasodepression and cardioinhibition during tilt-Induced vasovagal syncope","volume":"127","author":"van Dijk","year":"2020","journal-title":"Circ Res"},{"key":"2023041817401423300_euac154-B24","author":"Russo"},{"key":"2023041817401423300_euac154-B25","doi-asserted-by":"crossref","first-page":"1100","DOI":"10.1093\/europace\/euab024","article-title":"Age-related tilt test responses in patients with suspected reflex syncope","volume":"23","author":"Rivasi","year":"2021","journal-title":"Europace"},{"key":"2023041817401423300_euac154-B26","doi-asserted-by":"crossref","first-page":"1693","DOI":"10.1016\/j.amjcard.2011.01.057","article-title":"Effect of clinical triggers on positive responses to tilt-table testing potentiated with nitroglycerin or clomipramine","volume":"107","author":"Furukawa","year":"2011","journal-title":"Am J Cardiol"},{"key":"2023041817401423300_euac154-B27","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1053\/eupc.2000.0125","article-title":"\u2018The Italian protocol\u2019: a simplified head-up tilt testing potentiated with oral nitroglycerin to assess patients with unexplained syncope","volume":"2","author":"Bartoletti","year":"2000","journal-title":"Europace"},{"key":"2023041817401423300_euac154-B28","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1053\/eupc.1999.0064","article-title":"New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification","volume":"2","author":"Brignole","year":"2000","journal-title":"Europace"},{"key":"2023041817401423300_euac154-B29","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1161\/CIRCEP.113.001103","article-title":"Benefit of pacemaker therapy in patients with presumed neurally mediated syncope and documented asystole is greater when tilt test is negative an analysis from the third international study on syncope of uncertain etiology (ISSUE-3)","volume":"7","author":"Brignole","year":"2014","journal-title":"Circ Arrhythm Electrophysiol"},{"key":"2023041817401423300_euac154-B30","doi-asserted-by":"crossref","first-page":"1362","DOI":"10.1093\/europace\/eux321","article-title":"The benefit of pacemaker therapy in patients with neurally mediated syncope and documented asystole: a meta-analysis of implantable loop recorder studies","volume":"20","author":"Brignole","year":"2018","journal-title":"Europace"},{"key":"2023041817401423300_euac154-B31","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1093\/eurheartj\/ehaa936","article-title":"Cardiac pacing in severe recurrent reflex syncope and tilt-induced asystole","volume":"42","author":"Brignole","year":"2021","journal-title":"Eur Heart J"},{"key":"2023041817401423300_euac154-B32","doi-asserted-by":"crossref","first-page":"821","DOI":"10.1016\/j.hrthm.2020.01.029","article-title":"Pacing in vasovagal syncope: physiology, pacemaker sensors and recent clinical trials. Precise patient selection and measurable benefit","volume":"17","author":"Sutton","year":"2020","journal-title":"Heart Rhythm"},{"key":"2023041817401423300_euac154-B33","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1007\/s10286-020-00738-6","article-title":"Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness: consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN)","volume":"31","author":"Thijs","year":"2021","journal-title":"Clin Auton Res"}],"container-title":["Europace"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/europace\/article-pdf\/25\/2\/263\/50013837\/euac154.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/europace\/article-pdf\/25\/2\/263\/50013837\/euac154.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,4,18]],"date-time":"2023-04-18T17:58:52Z","timestamp":1681840732000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/europace\/article\/25\/2\/263\/6691831"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,9,5]]},"references-count":33,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2022,9,5]]},"published-print":{"date-parts":[[2023,2,16]]}},"URL":"https:\/\/doi.org\/10.1093\/europace\/euac154","relation":{},"ISSN":["1099-5129","1532-2092"],"issn-type":[{"value":"1099-5129","type":"print"},{"value":"1532-2092","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2023,2,1]]},"published":{"date-parts":[[2022,9,5]]}}}