An approach to the evaluation and management of syncope in adults

In their review on the evaluation and management of syncope in adults [1], Parry and Tan do not discuss tilt training (or orthostatic training), although they do mention raising the head of the bed during sleep.



Ectors and co-authors from my institution first reported that repetitive tilting (60° of inclination) could have a beneficial effect in some patients with neurocardiogenic syncope and orthostatic intolerance [2]. Long-term follow-up showed that syncope recurred in a subgroup of this original cohort who had ceased training [3].



An early controlled non-randomized study showed very promising results in adolescents [4]. Another controlled non-randomized study found that tilt training was far more effective than drug therapy with propranolol or disopyramide [5]. Tilt training was also effective in adults with vasovagal syncope in a non-randomized controlled study [6].



Subsequent randomized trials were mainly negative, although adherence was problematic [7-10]. The largest and most recent of these found a significant benefit in those patients with vasodepressor-type vasovagal syncope [10].



The available evidence is limited to small trials which were probably underpowered. Pary and Tan themselves recently conducted the first placebo-controlled randomized trial of tilt training vs. sham training, providing the proof of principle for a much needed larger randomized trial [11].



In conclusion, the effectiveness of tilt training remains disputed, although I believe it might still be offered to highly motivated patients, given that it is well tolerated and that it can give patients a sense of control over their condition.


References

1. Parry SW, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ 2010;340:c880.
2. Ector H, Reybrouck T, Heidbüchel H, Gewillig M, Van de Werf F. Tilt training: a new treatment for recurrent neurocardiogenic syncope and severe orthostatic intolerance. Pacing Clin Electrophysiol 1998;21(1 Pt 2):193-6.
3. Reybrouck T, Heidbüchel H, Van De Werf F, Ector H. Long-term follow-up results of tilt training therapy in patients with recurrent neurocardiogenic syncope. Pacing Clin Electrophysiol 2002;25(10):1441-6.
4. Di Girolamo E, Di Iorio C, Leonzio L, Sabatini P, Barsotti A. Usefulness of a tilt training program for the prevention of refractory neurocardiogenic syncope in adolescents: a controlled study. Circulation 1999;100(17):1798-801.
5. Abe H, Sumiyoshi M, Kohshi K, Nakashima Y. Effects of orthostatic self-training on head-up tilt testing for the prevention of tilt-induced neurocardiogenic syncope: comparison of pharmacological therapy. Clin Exp Hypertens. 2003;25(3):191-8.
6. Gajek J, Zyśko D, Mazurek W. Efficacy of tilt training in patients with vasovagal syncope. Kardiol Pol 2006;64(6):602-8.
7. Foglia-Manzillo G, Giada F, Gaggioli G, Bartoletti A, Lolli G, Dinelli M et al. Efficacy of tilt training in the treatment of neurally mediated syncope: a randomized study. Europace 2004;6(3):199-204.
8. On YK, Park J, Huh J, Kim JS. Is home orthostatic self-training effective in preventing neurally mediated syncope? Pacing Clin Electrophysiol 2007;30(5):638-43.
9. Gurevitz O, Barsheshet A, Bar-Lev D, Zimlichman E, Rosenfeld GF, Benderly M et al. Tilt training: does it have a role in preventing vasovagal syncope? Pacing Clin Electrophysiol 2007;30(12):1499-505.
10. Duygu H, Zoghi M, Turk U, Akyuz S, Ozerkan F, Akilli A et al. The role of tilt training in preventing recurrent syncope in patients with vasovagal syncope: a prospective and randomized study. Pacing Clin Electrophysiol 2008;31(5):592-6.
11. Tan MP, Newton JL, Chadwick TJ, Gray JC, Nath S, Parry SW. Home orthostatic training in vasovagal syncope modifies autonomic tone: results of a randomized, placebo-controlled pilot study. Europace 2010;12(2):240-6.