Autonomic uprising: the tilt table test in autonomic medicine


This perspective piece on head-up tilt table testing is part of a series on autonomic function testing. The tilt table can be a useful diagnostic test, but methodologies vary, and the results are sometimes misinterpreted. The intent here is not to review comprehensively the utility of various tilt table testing protocols but to convey a number of general points that may give perspective and have practical clinical value, based on an understanding of autonomic physiology and our long clinical and research experience in the evaluation of autonomic disorders. The goals of tilt table testing are to assess orthostatic hypotension (OH), chronic orthostatic intolerance (COI), and unexplained syncope. The testing is useful for distinguishing neurogenic from non-neurogenic OH, identifying failure of the sympathetic noradrenergic system in autonomic neuropathies and ganglionopathies, and assessing baroreflex-sympathoneural function in α-synucleinopathies. For COI, the testing can provide objective data related to the patient’s symptoms, diagnose postural tachycardia syndrome (POTS), and distinguish POTS from other causes of tachycardia. Provocative tilt table testing can help understand bases for recurrent transient loss of consciousness in patients with syncope, distinguish neurally mediated syncope from psychogenic pseudosyncope, and separate syncope-related convulsion from epileptic seizures. For each of these purposes, the goals, formats, endpoints, and clinical utility are different. As for any autonomic test, tilt table findings must be interpreted in the context of the patient’s clinical presentation.

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Fig. 1
Fig. 2
Fig. 3a–f



Autonomic nervous system


Blood pressure


Chronic orthostatic intolerance




Forearm vascular resistance


Heart rate


Head-up tilt




Cell membrane norepinephrine transporter


Neurally mediated hypotension


Neurogenic orthostatic hypotension


Orthostatic hypotension


Postural tachycardia syndrome


Sympathetic noradrenergic system


Cardiac stroke volume


  1. 1.

    Niemitz C (2010) The evolution of the upright posture and gait—a review and a new synthesis. Naturwissenschaften 97:241–263

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Goldstein DS, Cheshire WP (2017) The autonomic medical history. Clin Auton Res 27:223–233

    Article  PubMed  Google Scholar 

  3. 3.

    Cheshire WP, Goldstein DS (2018) The physical examination as a window into autonomic disorders. Clin Auton Res 28:23–33

    Article  PubMed  Google Scholar 

  4. 4.

    Smith JJ, Porth CM, Erickson M (1994) Hemodynamic response to the upright posture. J Clin Pharmacol 34:375–386

    Article  CAS  PubMed  Google Scholar 

  5. 5.

    Waterfield RL (1931) The effects of posture on the circulating blood volume. J Physiol 72:110–120

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Thompson WO, Thompson PK, Dailey ME (1928) The effect of posture upon the composition and volume of the blood in man. J Clin Invest 5:573–604

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Borst C, van Brederode JF, Wieling W, van Montfrans GA, Dunning AJ (1984) Mechanisms of initial blood pressure resposne to postural change. Clin Sci (Lond) 67:321–327

    Article  CAS  Google Scholar 

  8. 8.

    Nilsson D, Sutton R, Tas W, Burri P, Melander O, Fedorowski A (2015) Orthostatic changes in hemodynamics and cardiovascular biomarkers in dysautonomic patients. PLoS One 10(6):e0128962

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Harvey W (1628) Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus. Leake CD, trans., Fifth Edition, Springfield, IL: Charles C. Thomas, 1970

  10. 10.

    Hoffman F (1740) De situ erecto in morbis periculosis valde noxio. Opera Omnia Physico Med 6:169–173

    Google Scholar 

  11. 11.

    Piorry PA (1830) Du procédé operatoire, & c. of the operative process to be followed in the examination of organs by mediate percussion, and a collection of memoirs on physiology, pathology, and diagnosis. Edinburgh Med Surg J 43:417–427

    Google Scholar 

  12. 12.

    Hill L (1895) The influence of the force of gravity on the circulation of the blood. J Physiol 18:15–53

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Hill L, Barnard H (1897) The influence of the force of gravity on the circulation. J Physiol 21:323–352

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Langley JN (1898) On the union of cranial autonomic (visceral) fibres with nerve cells of the superior cervical ganglion. J Physiol 23:240–270

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Langley JN (1891) Note on the connection with nerve-cells of the vaso-motor nerves for the feet. J Physiol 12:375–377

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Langley JN (1923) The vascular dilatation caused by the sympathetic and the course of vaso-motor nerves. J Physiol 58:70–73

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Helmreich E (1923) Statische und dynamische Pulsacceleration. Z Ges Exp Med 36:226–235

    Article  Google Scholar 

  18. 18.

    Turner AH, Newton MI, Haynes FW (1930) The circulatory reaction to gravity in healthy young women. Am J Physiol 94:507–520

    Article  Google Scholar 

  19. 19.

    Kenny RA, Ingram A, Bayliss J, Sutton R (1986) Head-up tilt: a useful test for investigating unexplained syncope. Lancet 1(8494):1352–1355

    Article  CAS  PubMed  Google Scholar 

  20. 20.

    Bearn AG, Billing B, Edholm OG, Sherlock S (1951) Hepatic blood flow and carbohydrate changes in man during fainting. J Physiol 115:442–455

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. 21.

    McCally M, Piemme TE, Murray RH (1966) Tilt table responses of human subjects following application of lower body negative pressure. Aerosp Med 37:1247–1249

    CAS  PubMed  Google Scholar 

  22. 22.

    El Bedawi KM, Hainsworth R (1994) Combined head-up tilt and lower body suction: a test of orthostatic tolernace. Clin Auton Res 43:41–47

    Article  Google Scholar 

  23. 23.

    Protheroe CL, Ravensbergen HR, Inskip JA, Claydon VE (2013) Tilt testing with combined lower body negative pressure: a “gold standard” for measuring orthostatic tolerance. J Vis Exp 73:e4315.

    Article  Google Scholar 

  24. 24.

    Weiss S, Wilkins RW, Haynes FW (1937) The nature of circulatory collapse induced by sodium nitrite. J Clin Invest 16:73–84

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Waxman MB, Yao L, Cameron DA, Wald RW, Roseman J (1989) Isoproterenol induction of vasodepressor-type reaction in vasodepressor-prone persons. Am J Cardiol 63:58–65

    Article  CAS  PubMed  Google Scholar 

  26. 26.

    Raviele A, Gasparini G, Di Pede F, Menozzi C, Brignole M, Dinelli M, Alboni P, Piccolo E (1994) Nitroglycerin infusion during upright tilt: a new test for the diagnosis of vasovagal syncope. Am Heart J 127:103–111

    Article  CAS  PubMed  Google Scholar 

  27. 27.

    Raviele A, Menozzi C, Brignole M, Gasparini G, Alboni P, Musso G, Lolli G, Oddone D, Dinelli M, Mureddu R (1995) Value of head-up tilt testing potentiated with sublingual nitroglycerin to assess the origin of unexplained syncope. Am J Cardiol 76:267–272

    Article  CAS  PubMed  Google Scholar 

  28. 28.

    Tanaka H, Sjöberg BJ, Thulesius O (1996) Cardiac output and blood pressure during active and passive standing. Clin Physiol 16:157–170

    Article  CAS  PubMed  Google Scholar 

  29. 29.

    Sprangers RL, Wesseling KH, Imholz AL, Imholz BP, Wieling W (1985) Initial blood pressure fall on stand up and exercise explained by changes in total peripheral resistance. J Appl Physiol 70:523–530

    Article  Google Scholar 

  30. 30.

    Wieling W, Harms MP, Kortz RA, Linzer M (2001) Initial orthostatic hypotension as a cause of recurrent syncope: a case report. Clin Auton Res 11:269–270

    Article  CAS  PubMed  Google Scholar 

  31. 31.

    Wieling W, Krediet CT, van Dijk N, Linzer M, Tschakovsky ME (2007) Initial orthostatic hypotension: review of a forgotten condition. Clin Sci (Lond) 112:157–165

    Article  Google Scholar 

  32. 32.

    Aydin AE, Soysal P, Isik AT (2017) Which is preferable for orthostatic hypotension diagnosis in older adults: active standing trest or head-up tilt table test? Clin Interv Aging 12:207–212

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Borst C, Wieling W, van Brederode JF, Hond A, de Rijk LG, Dunning AJ (1982) Mechanisms of initial heart rate response to postural change. Am J Physiol 243:H676–H681

    CAS  PubMed  Google Scholar 

  34. 34.

    Ewing DJ, Hume L, Campbell IW, Murray A, Neilson JM, Clarke BF (1980) Autonomic mechanisms in the initial heart rate response to standing. J Appl Physiol Respir Environ Exerc Physiol 59:809–814

    Google Scholar 

  35. 35.

    Lewis NC, Atkinson G, Lucas SJ, Grant EJ, Jones H, Tzeng YC, Horsman H, Ainslie PN (2010) Diurnal variation in time to presyncope and associated circulatory changes during a controlled orthostatic challenge. Am J Physiol Regul Integr Comp Physiol 299:R55–R61

    Article  CAS  PubMed  Google Scholar 

  36. 36.

    Zoghi M, Duygu H, Gungor H, Nalbantgil S, Ozerkan F, Akilli A, Akin M (2008) Circadian and infradian rhythms of vasovagal syncope in young and middle-aged subjects. Pacing Clin Electrophysiol 31:1581–1584

    Article  PubMed  Google Scholar 

  37. 37.

    Mineda Y, Sumiyoshi M, Tokano T, Yasuda M, Nakazato K, Nakazato Y, Nakata Y, Yamaguchi H (2000) Circadian variation of vasovagal syncope. J Cardiovasc Electrophysiol 11:1078–1080

    Article  CAS  PubMed  Google Scholar 

  38. 38.

    Brewster JA, Garland EM, Biaggioni I, Black BK, Ling JF, Shibao CA, Robertson D, Raj SR (2012) Diurnal variability in orthostatic tachycardia: implications for the postural tachycardia syndrome. Clin Sci (Lond) 122:25–31

    Article  Google Scholar 

  39. 39.

    Lewis NC, Ainslie PN, Atkinson G, Jones H, Grant EJ, Lucas SJ (2012) The effect of time-of-day and sympathetic α1-blockade on orthostatic tolerance. Chronobiol Int 29:882–890

    Article  CAS  PubMed  Google Scholar 

  40. 40.

    Lewis NC, Atkinson G, Lucas SJ, Grant EJ, Jones H, Tzeng YC, Horsman H, Ainslie PN (2011) Is there diurnal variation in initial and delayed orthostatic hypotension during standing and head-up tilt? Chronobiol Int 28:135–145

    Article  CAS  PubMed  Google Scholar 

  41. 41.

    Maurer MS, Karmally W, Rivadeneira H, Parides MK, Bloomfield DM (2000) Upright posture and postprandial hypotension in elderly persons. Ann Intern Med 133:533–536

    Article  CAS  PubMed  Google Scholar 

  42. 42.

    Teramoto S, Akishita M, Fukuchi Y, Toba K, Ouchi Y (1997) Assessment of autonomic nervous function in elderly subjects with or without postprandial hypotension. Hypertens Res 20:257–261

    Article  CAS  PubMed  Google Scholar 

  43. 43.

    Thomaides T, Bleasdale-Barr K, Chaudhuri KR, Pavitt D, Marsden CD, Mathias CJ (1993) Cardiovascular and hormonal responses to liquid food challenge in idiopathic Parkinson’s disease, multiple system atrophy, and pure autonomic failure. Neurology 43:900–904

    Article  CAS  PubMed  Google Scholar 

  44. 44.

    Shen W-K, Jahangir A, Beinborn D, Lohse CM, Hodge DO, Rea RF, Hammill SC (1999) Utility of a single-stage isoproterenol tilt table test in adults. J Am Coll Cardiol 33:985–990

    Article  CAS  PubMed  Google Scholar 

  45. 45.

    Saal DP, Thijs RD, van Dijk JG (2016) Tilt table testing in neurology and clinical neurophysiology. Clin Neurophysiol 127:1022–1030

    Article  CAS  PubMed  Google Scholar 

  46. 46.

    Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch EE, Biaggioni I, Cheshire WP, Chelimsky T, Cortelli P, Gibbons CH, Goldstein DS, Hainsworth R, Hilz MJ, Jacob G, Kaufmann H, Jordan J, Lipsitz LA, Levine BD, Low PA, Mathias C, Raj SR, Robertson D, Sandroni P, Schatz I, Schondorf R, Stewart JM, van Dijk JG (2011) Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 21:69–72

    Article  PubMed  Google Scholar 

  47. 47.

    Kamiya A, Kawada T, Shimizu S, Iwase S, Sugimachi M, Mano T (2009) Slow head-up tilt causes lower activation of muscle sympathetic nerve activity: loading speed dependence of orthostatic sympathetic activation in humans. Am J Physiol Heart Circ Physiol 297:H53–H58

    Article  CAS  PubMed  Google Scholar 

  48. 48.

    Shamsuzzaman AS, Sugiyama Y, Kamiya A et al (1998) Head-up suspension in humans: effects on sympathetic vasomotor activity and cardiovascular responses. J Appl Physiol 84:1513–1519

    Article  CAS  PubMed  Google Scholar 

  49. 49.

    Fedorowski A, Hamrefors V, Sutton R, van Dijk JG, Freeman R, Lenders JW, Wieling W (2017) Do we need to evaluate diastolic blood pressure in patients with suspected orthostatic hypotension? Clin Auton Res 27:167–173

    Article  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Romero-Ortuno R, Cogan L, Fan CW, Kenny RA (2010) Intolerance to initial orthostasis relates to systolic BP changes in elders. Clin Auton Res 20:39–45

    Article  PubMed  Google Scholar 

  51. 51.

    Goldstein DS, Holmes C, Frank SM, Naqibuddin M, Dendi R, Snader S, Calkins H (2003) Sympathoadrenal imbalance before neurocardiogenic syncope. Am J Cardiol 91:53–58

    Article  PubMed  Google Scholar 

  52. 52.

    Heyer GL, Harvey RA, Islam MP (2018) Signs of autonomic arousal precede tilt-induced psychogenic nonsyncopal collapse among youth. Epilepsy Behav 86:166–172

    Article  PubMed  Google Scholar 

  53. 53.

    Norcliffe-Kaufmann L, Galindo-Mendez B, Garcia-Guarniz AL, Villarreal-Vitorica E, Novak V (2018) Transcranial Doppler in autonomic testing: standards and clinical applications. Clin Auton Res 28:187–202

    Article  PubMed  Google Scholar 

  54. 54.

    Cheshire WP (2017) Clinical classification of orthostatic hypotensions. Clin Auton Res 27:133–135

    Article  PubMed  Google Scholar 

  55. 55.

    Goldstein DS (2009) Neurogenic orthostatic hypotension: a pathophysiological approach. Circulation 119:139–146

    Article  PubMed  PubMed Central  Google Scholar 

  56. 56.

    Cheshire WP (2019) Chemical pharmacotherapy for the treatment of orthostatic hypotension. Expert Opin Pharmacother 20:187–199.

  57. 57.

    Norcliffe-Kaufmann L, Kaufmann H, Palma JA, Shibao CA, Biaggioni I, Peltier AC, Singer W, Low PA, Goldstein DS, Gibbons CH, Freeman R, Robertson D (2018) Orthostatic heart rate changes in patients with autonomic failure caused by neurodegenerative synucleinopathies. Ann Neurol 83:522–531

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Vogel ER, Sandroni P, Low PA (2005) Blood pressure recovery from Valsalva maneuver in patients with autonomic failure. Neurology 65:1533–1537

    Article  PubMed  Google Scholar 

  59. 59.

    Gibbons CH, Freeman R (2015) Clinical implications of delayed orthostatic hypotension: a 10-year follow-up study. Neurology 85:1362–1367

    Article  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Lahrmann H, Cortelli P, Hilz M, Mathias CJ, Struhal W, Tassinari M (2006) EFNS guidelines on the diagnosis and management of orthostatic hypotension. Eur J Neurol 13:930–936

    Article  CAS  PubMed  Google Scholar 

  61. 61.

    Cheshire WP (2019) Artifact in autonomic neurophysiology studies. In: Tatum WO (ed) Atlas of Artifacts in Clinical Neurophysiology. Springer, New York, pp 237–258

    Google Scholar 

  62. 62.

    Cheshire WP (2016) Stimulant medication and postural orthostatic tachycardia syndrome: a tale of two cases. Clin Auton Res 26:229–233

    Article  PubMed  Google Scholar 

  63. 63.

    Sheldon RS, Grubb BP, Olshansky B, Shen W-K, Calkins H, Brignole M, Raj SR, Krahn AD, Morillo CA, Stewart JM, Sutton R, Sandroni P, Friday KJ, Hachul DT, Cohen MI, Lau DH, Mayuga KA, Moak JP, Sandhu RK, Kanjwal K (2015) 2015 Heart Rhythm Society Expert Consensus Statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm 12:e41–e63

  64. 64.

    Grubb BP (2005) Neurocardiogenic syncope. N Engl J Med 352:1004–1010

    Article  CAS  PubMed  Google Scholar 

  65. 65.

    Moya A, Sutton R, Ammirati F, Blanc J-J, Brignole M, Dahm JB, Deharo J-C, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Granell RR, Sarasin F, Ungar A, van Dijk JG, Walma EP, Wieling W et al (2009) Guidelines for the diagnosis and management of syncope. The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J 30:2631–2671

  66. 66.

    Wieling W, Thijs RD, van Dijk N, Wilde AA, Benditt DG, van Dijk JG (2009) Symptoms and signs of syncope: a review of the link between physiology and clinical clues. Brain 132:2630–2642

    Article  PubMed  Google Scholar 

  67. 67.

    Ganzeboom KS, Mairuhu G, Reitsma JB, Linzer M, Wieling W, van Dijk N (2006) Lifetime cumulative incidence of syncope in the general population: a study of 549 Dutch subjects aged 35–60 years. J Cardiovasc Electrophysiol 17:1172–1176

    Article  PubMed  Google Scholar 

  68. 68.

    Solbiati M, Casazza G, Dipaola F, Rusconi AM, Cernuschi G, Barbic F, Montano N, Sheldon RS, Furlan R, Costantino G (2015) Syncope recurrence and mortality: a systematic review. Europace 17:300–308

    Article  PubMed  Google Scholar 

  69. 69.

    Novak V, Honos G, Schondorf R (1996) Is the heart “empty” at syncope? J Auton Nerv Syst 60:83–92

    Article  CAS  PubMed  Google Scholar 

  70. 70.

    Scherrer U, Vissing S, Morgan BJ, Hanson P, Victor RG (1990) Vasovagal syncope after infusion of a vasodilator in a heart transplant recipient. N Engl J Med 322:602–604

    Article  CAS  PubMed  Google Scholar 

  71. 71.

    Mitro P, Hijová E (2006) Myocardial contractility and cardiac filling measured by impedance cardiography in patient with nitroglycerine-induced vasovagal syncope. PACE 29:1–8

    Article  PubMed  Google Scholar 

  72. 72.

    Vaddadi G, Esler MD, Dawood T, Lambert E (2010) Persistence of muscle sympathetic nerve activity during vasovagal syncope. Eur Heart J 31:2027–2033

    Article  PubMed  Google Scholar 

  73. 73.

    Cooke WH, Rickards CA, Ryan KL, Kuusela TA, Convertino VA (2009) Muscle sympathetic nerve activity during intense lower body negative pressure to presyncope in humans. J Physiol 587:4987–4999

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  74. 74.

    Fu Q, Levine BD (2014) Pathophysiology of neurally mediated syncope: role of cardiac output and total peripheral resistance. Auton Neurosci 184:24–26

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  75. 75.

    Fu Q, Verheyden B, Wieling W, Levine BD (2012) Cardiac output and sympathetic vasocontrictor responses during upright tilt to presyncope in healthy humans. J Physiol 590:1839–1848

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  76. 76.

    Stewart JM, Sutton R, Kothari ML, Goetz AM, Visintainer P, Medow MS (2017) Nitric oxide synthase inhibition restores orthostatic tolerance in young vasovagal syncope patients. Heart 103:1711–1718

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  77. 77.

    Norcliffe-Kaufmann L, Kaufmann H, Hainsworth R (2007) Enhanced vascular responses to hypocapnia in neurally mediated syncope. Ann Neurol 63:288–294

    Article  Google Scholar 

  78. 78.

    Engel GL (1978) Psychologic stress, vasodepressor (vasovagal) syncope, and sudden death. Ann Intern Med 89:403–412

    Article  CAS  PubMed  Google Scholar 

  79. 79.

    Ganzeboom KS, Colman N, Reitsma JB, Shen WK, Wieling W (2003) Prevalence and triggers of syncope in medical students. Am J Cardiol 91:1006–1008

    Article  PubMed  Google Scholar 

  80. 80.

    Jamjoom AAB, Nikkar-Esfahani A, Fitzgerald JEF (2009) Operating theatre related syncope in medical students: a cross sectional study. BMC Med Educ 9:14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  81. 81.

    Kim JB, Suh S-I, Seo W-K, Koh S-B, Kim JH (2014) Right insular atrophy in neurocardiogenic syncope: a volumetric MRI study. AJNR Am J Neuroradiol 34:113–118

    Article  Google Scholar 

  82. 82.

    Diehl RR, Linden D, Chalkiadaki A, Diehl A (1999) Cerebrovascular mechanisms in neurocardiogenic syncope with and without postural tachycardia syndrome. J Auton Nerv Syst 76:159–166

    Article  CAS  PubMed  Google Scholar 

  83. 83.

    Cheshire WP (2017) Syncope. Continuum 23:335–358

    PubMed  Google Scholar 

  84. 84.

    Finsterer J, Stöllberger C (2016) Neurological complications of cardiac disease (heart brain disorders). Minerva Med 107:14–25

    PubMed  Google Scholar 

  85. 85.

    Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ, Bloch Thomsen PE, van Dijk JG, Fitzpatrick A, Hohnloser S, Janousek J, Kapoor W, Kenny RA, Kulakowski P, Masotti G, Moya A, Raviele A, Sutton R, Theodorakis G, Ungar A, Wieling W, European Society of Cardiology Task Force on Syncope (2004) Guidelines on management (diagnosis and treatment) of syncope—update 2004. Europace 6:467–537

  86. 86.

    Mittal S, Stein KM, Markowitz SM, Iwai S, Guttigoli A, Lerman BB (2004) Single-stage adenosine tilt testing in patients with unexplained syncope. J Cardiovasc Electrophysiol 15:637–640

    Article  PubMed  Google Scholar 

  87. 87.

    Theodorakis GN, Markianos M, Zarvalis E, Livanis EG, Flevari P, Kremastinos DT (2000) Provocation of neurocardiogenic syncope by clomipramine administration during the head-up tilt test in vasovagal syndrome. J Am Coll Cardiol 36:174–178

    Article  CAS  PubMed  Google Scholar 

  88. 88.

    Almquist A, Goldenberg IF, Milstein S, Chen M-Y, Chen X, Hansen R, Cornick CC, Benditt DG (1989) Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med 320:346–351

    Article  CAS  PubMed  Google Scholar 

  89. 89.

    Leman RB, Clarke E, Gillette P (1999) Significant complications can occur with ischemic heart disease and tilt table testing. PACE 22:675–677

    Article  CAS  PubMed  Google Scholar 

  90. 90.

    Aerts AJ, Dendale P (2003) Nitrate stimulated tilt table testing: a review of the literature. Pacing Clin Electrophysiol 26:1528–1537

    Article  PubMed  Google Scholar 

  91. 91.

    Stevens PM (1966) Cardiovascular dynamics during orthostatis and the influence of intravascular instrumentation. Am J Cardiol 17:211–218

    Article  CAS  PubMed  Google Scholar 

  92. 92.

    Aerts AJ, Dendale P, Block P, Dassen WR (2005) Reproducibility of nitrate-stimulated tilt testing in patients with suspected vasovagal syncope and a healthy control group. Am Heart J 150:251–256

    Article  CAS  PubMed  Google Scholar 

  93. 93.

    Delépine S, Prunier F, Lefthériotis G, Dupuis J, Vielle B, Geslin P, Victor J (2002) Comparison between isoproterenol and nitroglycerin sensitized head-upright tilt in patients with unexplained syncope and negative or positive passive head-up tilt response. Am J Cardiol 90:488–491

    Article  PubMed  Google Scholar 

  94. 94.

    Prabhu MA, Pillai V, Shenthar J (2017) Comparison of efficacy, pattern of response, occurrence of arrhythmias, and the tolerability of nitroglycerine and isoprenaline as provocative drugs during head-up tilt test. Heart Lung Circ 26:586–592

    Article  PubMed  Google Scholar 

  95. 95.

    Seymour RS, Hargens AR, Pedley TJ (1993) The heart works against gravity. Am J Physiol 265:R715–R720

    CAS  PubMed  Google Scholar 

  96. 96.

    Gavish B, Gavish L (2011) Blood pressure variation in response to changing arm cuff height cannot be explained solely by the hydrostatic effect. J Hypertens 29:2099–2104

    Article  CAS  PubMed  Google Scholar 

  97. 97.

    Wieling W, van Dijk N, de Lange FJ, Olde Nordkamp LRA, Thijs RD, van Dijk JG, Linzer M, Sutton R (2015) History taking as a diagnostic test in patients with syncope: developing expertise in syncope. Eur Heart J 36:277–280

    Article  PubMed  Google Scholar 

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Cheshire, W.P., Goldstein, D.S. Autonomic uprising: the tilt table test in autonomic medicine. Clin Auton Res 29, 215–230 (2019).

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  • Orthostatic intolerance
  • Orthostatic hypotension
  • Tilt table testing
  • Syncope
  • Vasovagal syncope
  • Postural orthostatic tachycardia syndrome
  • Autonomic nervous system diseases