Opinion Abolish the Tilt Table Test for the Workup of Syncope! 2020, Kulkarni et al

Abolish the Tilt Table Test for the Workup of Syncope!

Testing in medicine is done for a reason. A medical test should be performed to establish or reject a diagnosis, quantify disease severity, monitor disease progression, or identify a treatment that could not have been determined before the test. The ultimate outcome of a useful test and the consequent intervention should be either that it (1) reduces morbidity (improves quality of life) or (2) reduces mortality (increases the quantity of life). How well a test accomplishes these outcomes must come with an acceptable risk/benefit ratio. Even if a test (or intervention) does not cause harm itself, the consequences of making an incorrect diagnosis resulting in a wrong course of therapy may cause harm. It is within this context that we argue that tilt table testing (TTT) for the workup of syncope should be abolished. We submit that the TTT fails to establish an explicit cause of syncope, is plagued by false positives, and never plays a role in guiding treatment. Given these limitations, we believe that TTT should stop being administered for these purposes.

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https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.119.043259

 

Isn’t syncope (fainting) a potential symptom of severe POTS? They write this about POTS:

However, a simple active stand test is more clinically relevant, reproduces the circumstances of the patient’s complaint, and is just as sensitive but more specific than TTT for diagnosing these conditions.

I don’t see a source for this claim. Although one could argue that it’s the tilt test that should prove its relevance because it requires more resources. Idk which came first?

 

It seems the active stand test came first, but as far as I know neither of the tests appear to have too much clinical relevance in the context of ME/CFS (for syncope the standing test seems to have a lot of value as it directly can imply treatment.)

 

So if someone can get a critical article into what appears to be a key journal in their field, sticking the boot into the standard treatment, why can't we? Is it that tilt-table testing doesn't have powerful vested interests controlling the journals?

 

Probably.

 

It's so infuriating! This is exactly the sort of clear demolition of stupid, damaging rubbish that we want.

 

The researchers in this 2020 paper are concerned about the false positives, I'm more worried about the false negatives. No POTS, no dOH and still a CBF drop, that can only be measured with TTT and Doppler.
The researchers did not mention that. The Dutch researchers published in 2018, maybe Kulkarni et all were a bit behind with their research.

I visited a cardiologist, not the researchers, my GP included the TTT with Doppler test in the referral letter.

This cardiologist did not know about the added Doppler and did not find out or ask me.
He gave me a "third degree", I thought I'd walked into a police station in stead of a hospital. After the ECG, with the heartbeat noise so loud it hurt my ears, he tested my BP again, lying down and standing up.
My BP did not drop, I was all worked up, mad as hell. An iatrogenic white coat hypertension?
He wrote to my GP he had reassured me. No he did not. The data did. One side was at 70%, I knew both sides at 50% and added problems was chronic heart failure so one side at 70% meant I was in the clear; that was all I wanted to know.

 

Whilst it seems in the case of ME/CFS, the wrong thing is being measured, I would be wary of already being sure that CBF is the right thing. The dutch studies largely have the same problem as the studies we're criticising here. I think we'd need a metholodgically strong study on CBF before we can claim anything at all.

I feel like some of the CBF stuff has been based on a specific theory of reduced cognitive function (at least some of van Campens patients seem to come with these conclusions "ahh no wonder I can't think, by brain isn't getting supplied with what it needs"), but as far as we know cognition doesn't return to normal just because people with ME/CFS are lying down. Now some of the CBF studies might be showing that people already have reduced CBF when they are lying down, but then do things really line up nicely with orthostatic intolerance?