An approach to the evaluation and management of syncope in adultsBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c880 (Published 19 February 2010) Cite this as: BMJ 2010;340:c880
All rapid responses
We are delighted with the response from Professor Ectors' group. Tilt
training is recommended in consensus guidelines, but has a relatively poor
evidence base - the only sham-controlled randomised controlled trial is
our own pilot study, which incidentally showed that autonomic parameters
improved in tandem with symptoms in the tilt training intervention group.
(1) Such training (in our study, standing against a wall daily in safe
surroundings until usual vasovagal symptoms supervene, or for 25 minutes
with no lower leg movements) was not mentioned in our review because of
editorial and space constraints, but may be useful for a highly dedicated
patient group with adequate prodromal symptoms to abort any incipient
faint during training. The vast majority with vasovagal syncope, as
discussed in our review,(2) will get better with much less onerous
interventions such as adequate water drinking, physical counterpressure
manouvres and appropriate and early abortive action.
1. 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-
2. Parry SW, Tan MP. An approach to the evaluation and management of
syncope in adults. BMJ 2010;340:c880
Competing interests: No competing interests
In their review on the evaluation and management of syncope in adults , 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 . Long-term follow-up showed that syncope recurred in a subgroup of this original cohort who had ceased training .
An early controlled non-randomized study showed very promising results in adolescents . Another controlled non-randomized study found that tilt training was far more effective than drug therapy with propranolol or disopyramide . Tilt training was also effective in adults with vasovagal syncope in a non-randomized controlled study .
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 .
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 .
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.
- Parry SW, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ 2010;340:c880.
- 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.
- 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.
- 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.
- 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.
- Gajek J, Zyśko D, Mazurek W. Efficacy of tilt training in patients with vasovagal syncope. Kardiol Pol 2006;64(6):602-8.
- 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.
- 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.
- 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.
- 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.
- 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.
Competing interests: No competing interests