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Is Nitroglycerin Induced Pots & Oh Considered Positive Tilt-table Test?


Pokey

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I've been wondering whether the following is deemed a "positive" tilt-table test:

1) Horizontal -- pulse is 65; BP is 126/71.

2) Upright (without medication) -- pulse is 90; BP is 129/92 (seems like border-line hyperadrenergic POTs -- pulse a little shy of the normally required 28-30 point increase).

3) Upright after .3 mg of nitroglycerin is administered -- pulse is 115; BP is 96/72 (greater than 20 point drop in systolic, and 10 point drop in diastolic, suggestive of orthostatic hypotension); headache and nausea experienced (i.e., pre-syncope), but no syncope.

Test concluded orthostatic intolerance, likely caused by hypovolemia. (I don't know where the hypovolemia inference came from, as that is nothing more than one possible explanation for the drop in blood pressure.)

It's worth noting that my pulse normally increases 40+, and systolic drops 30+, when I go from lying to supine, and ANS testing has already confirmed POTS. But I am just wondering if this is considered a positive HUT/TTT. Based on my research, I believe it is, but it's tough to find definitive criteria where there is no syncope.

If anyone has any official, expansive criteria that they can direct me to, I would appreciate it.

Thanks a lot.

~P

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Guest brianala

I don't know if this answers your question precisely, but my doctor considers my tilt table test "positive" and I did not pass out until nitroglycerin was administered.

I don't know what all of my readings are since I don't have a copy of the test report (but I will be asking for one). I was standing for several minutes with no difficulty prior to the nitroglycerin; once that was administered I was out in under a minute.

As a result of the positive tilt table test I was diagnosed with neurocardiogenic syncope and orthostatic hypotension.

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I don't know if this answers your question precisely, but my doctor considers my tilt table test "positive" and I did not pass out until nitroglycerin was administered.

I don't know what all of my readings are since I don't have a copy of the test report (but I will be asking for one). I was standing for several minutes with no difficulty prior to the nitroglycerin; once that was administered I was out in under a minute.

As a result of the positive tilt table test I was diagnosed with neurocardiogenic syncope and orthostatic hypotension.

Thanks. Your test is definitely a positive. I did not pass out though; I just had pre-syncope symptoms.

I believe that people with POTS are less likely to pass out, as their hearts beat faster to balance the system. I believe most people with NCS have hypotension and bradycardia (i.e., BP and HR drops out, resulting in a lack of circulation to the brain). I was in decent condition at the time of my TTT; if it were a year earlier, when I was extremely weak, I would have been out for sure. I was having occasional black outs, and frequent gray outs, back then.

Again, thanks for the reply.

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I don't know the "official" answer to your question but I can tell you that none of the "top" facilities that research and study these disorders use nitroglycerin or any of the other drugs sometimes used at other places when they test patients.

I have always been told the test really isn't reliable if drugs are used as part of the test.

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I don't know the "official" answer to your question but I can tell you that none of the "top" facilities that research and study these disorders use nitroglycerin or any of the other drugs sometimes used at other places when they test patients.

I have always been told the test really isn't reliable if drugs are used as part of the test.

Hmm, that's interesting. Thanks. I've read a fair bit on the subject, and it seems to be a common practice -- essentially, it's trying to duplicate real-life stress, by kicking up your adrenaline, and seeing how your body responds, which seems to have value to me. But what do I know? It doesn't make much of a difference to me; I was curious more than anything about the test results. My doc prefers the poor person's TTT -- changing from a lying position to a standing position, and then taking vitals at various points in time in the supine position. This more closely reflects real-life movement, and requires home-grown adrenaline. She gave little attention to the TTT results, which were ordered by my cardiologists, before I began seeing a specialist.

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Most patients who have some form of autonomic disturbance don't "need" (for lack of a better word) a drug to "create stress". Standing up is enough stress for them. I think for most people the mere fact they are having to go through a testing procedure produces enough adrenaline naturally.

The literature shows repeatedly that in healthy sujects they had a much higher incidence of syncope or near syncope when given nitro or isoproterenol. Nitro is a vasodialator so it opens and widens all the blood vessels--that's why it's given to heart attack patients to help blood flow and create less work on the heart. Not everyone that gets nitro passes out but on the other hand if they did you couldn't say they have POTS or NCS or any other autonomic disorder.

I agree that the "poor man's tilt", as they call it, is probably most useful--people aren't as likey to lock their knees and stand in an awkward way as some of the TTT protocols do.

The TTT is useful but honestly, a lot of facilities do the test wrong and many folks don't know how to interpret the results and there is also growing concern that things are now shifting to the opposite end of the spectrum where patients are being misdiagnosed as having autonomic BASED problems. Doctors need to remember there is a list of criteria to be met when diagnosing patients--passing out, having tachy or brady or bp issues are symptoms of MANY conditions not just autonomic disorders. Having symptoms of autonomic dysfunction doesn't necessarily mean the underlying condition or disease is an ANS disorder.

I'm glad you have a good Dr working with you!

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Most patients who have some form of autonomic disturbance don't "need" (for lack of a better word) a drug to "create stress". Standing up is enough stress for them. I think for most people the mere fact they are having to go through a testing procedure produces enough adrenaline naturally.

The literature shows repeatedly that in healthy sujects they had a much higher incidence of syncope or near syncope when given nitro or isoproterenol. Nitro is a vasodialator so it opens and widens all the blood vessels--that's why it's given to heart attack patients to help blood flow and create less work on the heart. Not everyone that gets nitro passes out but on the other hand if they did you couldn't say they have POTS or NCS or any other autonomic disorder.

I agree that the "poor man's tilt", as they call it, is probably most useful--people aren't as likey to lock their knees and stand in an awkward way as some of the TTT protocols do.

The TTT is useful but honestly, a lot of facilities do the test wrong and many folks don't know how to interpret the results and there is also growing concern that things are now shifting to the opposite end of the spectrum where patients are being misdiagnosed as having autonomic BASED problems. Doctors need to remember there is a list of criteria to be met when diagnosing patients--passing out, having tachy or brady or bp issues are symptoms of MANY conditions not just autonomic disorders. Having symptoms of autonomic dysfunction doesn't necessarily mean the underlying condition or disease is an ANS disorder.

I'm glad you have a good Dr working with you!

Thanks for posting this, Poohbear, this is great info. Does this mean that any TTT with a positive result using nitroglycerin is suspect, and should be re-evaluated by a physician more knowledgeable about ANS disorders?

None of my doctors (GP, cardiologist, electrophysiologist) have ever brought up dysautonomia, but all of my research has led me here so I have been assuming they are part of an ANS disorder. However, I understand now that there are many other related disorders that can cause ANS symptoms. How do you find out for sure?

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Brianala,

I am NOT a Dr so I can't give you a physician's answer.

I have been dealing autonomic dysfunction for well over 15 years. My first TTT was 12 years ago and I've had many along the way (as well as many many other tests). I've seen many of the "top" specialists in this field so it is through my own journey, tons of research and reading and lots of conversations with the specialists ---it's a combination of all of these things that I have learned from, but again....keep in mind that I am no Dr.

My PERSONAL OPINION is that a positive TTT after receiving nitro, isoproterenol or any other drug is potentially questionable. There are lots of factors that have to be considered. A patients test could clearly be positive prior to administration of any drug but the Dr may want to see what happens after one of these drugs is given. You could have a patient who had a test within normal limits who reacted only once one of the drugs was used. In my opinion these two scenarios (and there are many more) are very different. Physicians need to be educated and trained. A positive TTT in most any of these scenarios, in and of itself, is not enough for a definitive diagnosis from what I've read.

You could have a patient who maybe has a mild disturbance that only reacted with the drug on TTT--one that in general is not problematic in day-to-day life but if the Dr uses that one and only test to diagnose and treat the patient then potentially he could maybe be doing a disservice to the patient. Likewise, there are probably patients out there who benefit from the suggested treatment regardless of how their TTT turned out.

Here is a link that may help you with some of your questions http://www.pubmedcentral.nih.gov/articlere...i?artid=1501099

We hear about so many physicians that don't follow a good procedure for how the TTT is done and we know that can affect the outcome of the test.

For POTS it's several criteria that have to be met for diagnosis but as someone at Vanderbilt pointed out to me, "Remember....POTS is not an "end" diagnosis, it means we've identified you have a cluster of symptoms that fits the syndrome but there are probably a hundred different reasons why patients develop the syndrome and we just don't know yet what all of those are. Sometimes we get lucky and find the root cause, but to date, most of the time we do not"

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Brianala,

I am NOT a Dr so I can't give you a physician's answer.

I have been dealing autonomic dysfunction for well over 15 years. My first TTT was 12 years ago and I've had many along the way (as well as many many other tests). I've seen many of the "top" specialists in this field so it is through my own journey, tons of research and reading and lots of conversations with the specialists ---it's a combination of all of these things that I have learned from, but again....keep in mind that I am no Dr.

My PERSONAL OPINION is that a positive TTT after receiving nitro, isoproterenol or any other drug is potentially questionable. There are lots of factors that have to be considered. A patients test could clearly be positive prior to administration of any drug but the Dr may want to see what happens after one of these drugs is given. You could have a patient who had a test within normal limits who reacted only once one of the drugs was used. In my opinion these two scenarios (and there are many more) are very different. Physicians need to be educated and trained. A positive TTT in most any of these scenarios, in and of itself, is not enough for a definitive diagnosis from what I've read.

You could have a patient who maybe has a mild disturbance that only reacted with the drug on TTT--one that in general is not problematic in day-to-day life but if the Dr uses that one and only test to diagnose and treat the patient then potentially he could maybe be doing a disservice to the patient. Likewise, there are probably patients out there who benefit from the suggested treatment regardless of how their TTT turned out.

Here is a link that may help you with some of your questions http://www.pubmedcentral.nih.gov/articlere...i?artid=1501099

We hear about so many physicians that don't follow a good procedure for how the TTT is done and we know that can affect the outcome of the test.

For POTS it's several criteria that have to be met for diagnosis but as someone at Vanderbilt pointed out to me, "Remember....POTS is not an "end" diagnosis, it means we've identified you have a cluster of symptoms that fits the syndrome but there are probably a hundred different reasons why patients develop the syndrome and we just don't know yet what all of those are. Sometimes we get lucky and find the root cause, but to date, most of the time we do not"

Thanks Poohbear, this is all great info! While I know that most of us here aren't doctors, I think that the people on these boards have probably 'specialized' in these issues for longer than most of our actual physicians! It's been very confusing for me coming into this trying to learn what I have/don't have, what I need to follow up on, and just what any of my test results mean.

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Hi, juat seen this post so stepping in a bit late but I'll write what I have learnt about TTT over the past few years (had several TTT myself).

For a diagnosis of POTS the 30/min increase in HR should happen without medication.

For a diagnosis of orthostatic hypotension the drop in BP should happen without medication.

Some doctors say that a TTT is only positive if you loose consiousness - what they really mean is that it only proves a cause for syncope if you have syncope during the test.

The TTT was discovered as a way of inducing syncope in the lab so that blackouts could be investigated. It wasn't designed to test for POTS - in fact one of the early "modern" medical papers on POTS is basically saying "...we were testing for syncope and found this group of people with an unusual tachycardia during TTT...".

When testing for syncope the doctors want to know if a) the BP drops first (vasodepressor response) or :rolleyes: the HR drops / pauses first (cardioinhibitory response) or c) both happen together.

Some TTT protocols use GTN spray or Isoprenaline infusions to deliberately put stress on the vagal nerve. After being given one of those meds it is normal for anyone to get a low BP and a compensating fast HR. However it is not normal for anyone to get a bradycardia (slow HR) or for their heart to pause after the meds - if that reaction happens then it can be called a medication induced positive TTT. For everyone else I think that the reaction needs to have happened before the meds are given. This is why protocols designed to look for syncope use meds and protocols designed just to assess the ANS or look for POTS don't use medication. Basically there is no "standard TTT protocol" every doctor and hospital has their own way of doing the test. However for POTS the poor-man's tilt is perfect - if your HR goes up on normal standing it suggests you have POTS.

I hope that makes sense - as I said nothing is "standard" so I'm sure lots of people will have different opinions!

Flop

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I am shocked! What kind of doctor would give you nitroglycerine if he/she suspected POTS???

I would really question their competence.

The one hallmark of POTS is your heart rate going up without medication on the TTT. AND...without knowing how your body would respond, you risk putting yourself at risk...

Doing a TTT without compression, after several minutes, my heart suddenly went into a PSVT. I was extremely sick and weak afterwards. That was in a controlled environment on a real tilt table. I think I would have been clearly near serious danger or worse had I been given any medications!!! Especially nitroglycerine.

Please get yourself to a competent ANS doctor and testing center!

tearose

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Guest brianala
Some TTT protocols use GTN spray or Isoprenaline infusions to deliberately put stress on the vagal nerve. After being given one of those meds it is normal for anyone to get a low BP and a compensating fast HR. However it is not normal for anyone to get a bradycardia (slow HR) or for their heart to pause after the meds - if that reaction happens then it can be called a medication induced positive TTT. For everyone else I think that the reaction needs to have happened before the meds are given. This is why protocols designed to look for syncope use meds and protocols designed just to assess the ANS or look for POTS don't use medication. Basically there is no "standard TTT protocol" every doctor and hospital has their own way of doing the test. However for POTS the poor-man's tilt is perfect - if your HR goes up on normal standing it suggests you have POTS.

I hope that makes sense - as I said nothing is "standard" so I'm sure lots of people will have different opinions!

Flop

Is it ever "normal" to pass out, with or without the nitroglycerin?

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Is it ever "normal" to pass out, with or without the nitroglycerin?

Do you mean during the TTT or in general? If you mean is it normal to pass out during a TTT with or w/out the nitro I would say "it depends". if you pass out without the nitro that's not "normal" but it also doesn't necessarily mean there is anything dangerously wrong with you either (it could be either way---there could be something dangerous wrong but there might not be). If you pass out after being given nitro. then that may not be normal either but again...wouldn't mean there was necessarily anything truly wrong with you either especially under the conditions of having it happen in a TTT study.

As for passing out (sycope) in general--there are many reasons why a person could pass out. Some are a sign of a dangerous root cause but most are not. It goes back to needing to find the root cause if possible. Most people pass out at some point in their lives--in that sense it's "normal". If it's interferring with your life or connected to other symptoms then you certainly have to check it out, but again....there are hundreds of reasons why a person could pass out.

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Sorry Flop, trying to get a handle on how to reply to sugjects. I did have a tilt table done here in Phila at the Albert Einstein Braemer Heart Institute. I didn't pass out until the nitro was administered. I felt faint and woozy during the pre-nitro portion and not sure how low my pressure went because I never got the report, but I was told after I passed out and came to (what a horrid feeling!) that my b/p was 40 and my pulse was 130. I was sick for two days.

Flop, I noticed that you are on Paraxetine (generic Paxil). Sorry to change subjects but I wanted to know how you are doing on it. The reason I ask is that I'm to start it tomorrow. I never much cared for generics but that is all that my drug plan will allow.

I'm to start slowly 5mg (I'll probably take it down to 2.5). Has your heart been any more tachy since you started it? although I see you are on a beta blocker.

Just wanted your thoughts opinions about the drug.

Thank you so much.

Ruekat

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According to a medical article I?ve read:

POTS is defined (Table 1) as the presence of symptoms of orthostatic intolerance for at

least 6 months accompanied by a heart rate increase of at least 30 beats/min within 5-30 minutes

of assuming an upright posture. This should occur in the absence of orthostatic hypotension (a

fall in blood pressure >20/10 mmHg). The syndrome must occur in the absence of prolonged

bed rest, medications that impair autonomic regulation (such as vasodilators, diuretics,

antidepressants or anxiolytic agents), or any other chronic debilitating disorders that might cause

tachycardia (such as dehydration, anemia or hyperthyroidism). It is important to recognize that

this syndrome is typically disabling. Hence, the mere observation of orthostatic tachycardia is

not, by itself, sufficient to make the diagnosis of POTS.

Furthermore, Doctor Grubb also describes another type of POTS in which the heart rate increase and fall in blood pressure happens slowly, while standing for more than 30 minutes...

When I had my TTT done, after 15 minutes standing, my heart rate had increased from 80 bpm to 120 (an increase of 40 bpm).

My blood pressure had dropped from 120-60 to 107-54

Even though this is enough for me to dx POTS, the Cardiologist (who had no idea about POTS) said he was not patient enough to wait for the 45 minutes of the test and (besides the already clarifying results) after only 15 minutes standing, decided to use the sublingual Nitroglicerine Spray.

At that time we had no idea that I was having an adrenal insufficiency and therefore dangerously sensitive to vasodilators..

After only 3 minutes, I had a syncope.

According to the doctor I had developed a bradycardia... No further information.

When I had the syncope, the nurses tilted me down again with my legs above, but I did not regain consciousness... Time passed and nurses (and the Cardiologist) became worried and anxious, screaming my name and unsure of what to do...

My husband could hear their voices from the other side of the door and worried enough to think about entering the room...

For sure, the Cardiologist had to inyect a drug to help me cope with the reaction provoked by the NGN... Thanks God, I did recover.

I would bet that not only I had a bradycardia (which was confirmed after 5 minutes), but that my heart stopped beating when I had the syncope... But for 2 minutes, while I was without consciousness, the Cardiologist did not write my hr and bp.

5 minutes later, he wrote hr 50 and bp 64/26

But what was my hr and bp when I had the syncope? Who knows?

I think they all scared to death.

In fact, it could have been much worse...

Now I know that it was a circulatory shock (endocrine shock). A serious, life-threatening medical condition where insufficient blood flow reaches the body tissues and the muscle of the heart. A similar reaction happens with Anaphylaxis...

And

(rapid loss of blood pressure - can lead to heart failure and brain shut-down) and possibly die unless we quickly obtain medical assistance.

prolonged hypovolemia and hypotension does carry a risk of respiratory and then cardiac arrest.

Nowadays, I am fully aware that I have to avoid all kind of vasodilator drugs, unless used together with IV HC...

But that was pretty close. :(

And Tearose... I agree with you.

We are the only ones who really care about our health and who should be extremely careful with drugs...

I strongly recommend everyone always to check & investigate before using a prescribed drug ... Possible side effects, etc.

By the way, adrenal disorders (such as Addison disease, Adrenal insufficiency, hypopituitarismo, etc), can produce symptoms that mimic POTS, contributing to one's orthostatic intolerance....

Hope that this helps others.

Love

Tessa

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I am shocked! What kind of doctor would give you nitroglycerine if he/she suspected POTS???

I would really question their competence.

The one hallmark of POTS is your heart rate going up without medication on the TTT. AND...without knowing how your body would respond, you risk putting yourself at risk...

Doing a TTT without compression, after several minutes, my heart suddenly went into a PSVT. I was extremely sick and weak afterwards. That was in a controlled environment on a real tilt table. I think I would have been clearly near serious danger or worse had I been given any medications!!! Especially nitroglycerine.

Please get yourself to a competent ANS doctor and testing center!

tearose

Well, my POTS doctor did not order the TTT; it was my cardiologist. However, maybe he should have known better, as he did a poor man's tilt in the office, and my pulse went from 70 to 180, and then settled at around 130.

Personally, I think that the 24-Holter monitor is very valuable as part of a POTS diagnosis. My cardiologist saw the report and told me that I am anxious and need to try and relax, as my average HR was over 100 (not an exercise day). Then I saw a POTS cardiologist, and when I related this advice as she reviewed the Holter-monitor data, she laughed, commenting that apparently anxiety strikes whenever I go from a lying to standing position.

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Hypovolemia was my diagnosis 7 years ago. I had the dreaded TTT with no drugs. I actually did not even do the test.... during the 45 degree baseline tilt I went into a full syncope. At the time the told me it was "Idiopathic Hypovolemia" the main reason it was not outright POTS was the BPM did not increase as much as expected, but the BP drops further off then expected. Not sure if this applies in your situation or not just what I experienced.

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