Skip Navigation



European Heart Journal Advance Access published online on October 2, 2007
European Heart Journal, doi:10.1093/eurheartj/ehm430
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
28/21/2605    most recent
ehm430v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Foglia-Manzillo, G.
Right arrow Articles by Raviele, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Foglia-Manzillo, G.
Right arrow Articles by Raviele, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Tilt testing potentiated with sublingual nitroglycerin in children with unexplained syncope

Giovanni Foglia-Manzillo1,*, Franco Giada2, Nadia Fteita3, Italo Nessi4, Mauro Santarone1 and Antonio Raviele2

1 Cardiology Department, Ospedale Valduce, Via Dane, 11, 22100 Como, Italy
2 Cardiology Department, Ospedale Umberto I, Mestre-Venezia, Italy
3 Pediatric Neuropsychiatry Department, Ospedale S. Anna, Como, Italy
4 Emergency Department, Ospedale Valduce, Como, Italy

Received 22 May 2007; revised 8 August 2007; accepted 30 August 2007.

* Corresponding author. Tel: +39 031324133; fax: +39 031308047. E-mail address: gfoglia{at}valduce.it


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusions
 Funding
 References
 
Aims: The aim of this prospective study was to assess the diagnostic value of a sublingual nitroglycerin (NTG) potentiated head-up tilt (HUT) testing protocol in children with unexplained syncope.

Methods and results: One hundred and sixty-four consecutive paediatric patients with syncope of unknown origin and no evidence of organic heart disease (115 female, mean age 13 ± 3 years) and 29 control children underwent a sublingual NTG-potentiated tilt testing protocol. Paediatric patients and controls were tilted at 60° for 20 min and, if no symptom occurred, for other 15 min after sublingual 400 µg spray NTG administration. During the drug-free phase of the test, 13 patients (8%) and no controls had a positive response. After drug administration, a positive response occurred in another 88 patients (55%) and in four controls (14%), whereas an exaggerated response was observed in nine patients (5%) and in four controls (14%). Thus, the positive rate and specificity of sublingual NTG HUT test in children were 63 and 86%, respectively. No relevant adverse events were observed during the test.

Conclusion: Tilt testing potentiated with sublingual NTG has proved to be effective and safe in unmasking the neurally mediated origin of unexplained syncope in children. The NTG challenge greatly increased the positive rate of passive tilt, with a small decrease in specificity.

Key Words: Syncope • Children • Tilt testing • Nitroglycerin


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusions
 Funding
 References
 
Syncope is a common event in childhood.1–3 Among all the causes of syncope, neurally mediated syncope is reported to be the most frequent one.4–7 In children with unexplained syncope, conventional investigations have high costs and low diagnostic yield.8–10 The use of head-up tilt (HUT) testing has been increasing for the last years as a diagnostic tool in children with unexplained or suspected neurally mediated syncope.11 Many reports utilizing both passive and isoproterenol (IPN) provoked HUT testing have been published since the early '90s.12–16 Positivity rates in paediatric patients vary from 10.7 to 65% for passive HUT testing,15–20 whereas it ranges from 57 to 80% after IPN provocation.12,15,17,19–22 In children, specificity ranged from 48 to 100% for passive tilt testing,14,16,17,21,23–25 and in a single study was 87% after IPN stimulation.21 HUT test potentiated with sublingual nitroglycerin (NTG) has become popular for the evaluation of syncope in adults,26–29 but only a single small study investigated NTG challenge in children.30 The aim of this prospective study was to assess the diagnostic value of a sublingual NTG-potentiated HUT protocol in a large population of paediatric patients and in a control group of healthy children.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusions
 Funding
 References
 
Study population
One hundred and sixty-four consecutive paediatric patients, with syncope of unknown origin and no evidence of organic heart disease, and 29 control children were included in the study. The diagnosis of unexplained syncope was based on the exclusion of all other possible causes of syncope, by means of clinical history, physical examination, supine and orthostatic blood pressure determinations, and 12-lead surface electrocardiography. Other cardiac and neurological investigations such as echocardiography, 24 h Holter monitoring, exercise stress testing, electroencephalography, and computerized axial tomography or magnetic resonance imaging of the brain were performed only when clinically indicated. Patients were enrolled from June 2002 to October 2006. All consecutive patients <18 years old, who were referred for syncope of unknown origin, were deemed eligible for inclusion into the study. Of 168 eligible patients, four did not undergo tilt testing, because of parental refusal, and did not enter the study. Of 164 enrolled patients, 37 (23%) were in-hospital patients (admitted in the Pediatric Department); the remaining 127 children (77%) were out-patients, referred by paediatricians, paediatric neuropsychiatrists or cardiologist.

All control subjects were apparently healthy and had no previous syncopal or presyncopal episodes during their lifetime. Control subjects were enrolled among hospital workers' children <18 years old. Out of 60 eligible children, only 29 subjects entered the study, because of the high percentage of parental refusal.

The clinical characteristics of the patients and control children are shown in Table 1.


View this table:
[in this window]
[in a new window]

  		Table 1 Clinical characteristics of patients and control subjects

 
Head-up tilt test with sublingual nitroglycerin provocation
All paediatric patients and controls underwent HUT after informed parental consent. Children underwent HUT in the morning, after at least a 4 h fasting period. Continuous ECG monitoring of heart rate and rhythm was performed, whereas blood pressure was non-invasively measured beat to beat by means of an Ohmeda Finapres 2300 photopletismographic device.31,32 No intravascular instrumentation was used during the test. The Italian Protocol33 was utilized. After a stabilization phase of 5 min and baseline blood pressure and heart rate values measurement, children were tilted to 60° for 20 min on a manually controlled tilt-table with footplate support. If syncope did not develop during the initial passive phase, 400 µg spray NTG was administered sublingually, and children continued to be tilted for an additional 15 min. The endpoints of the test were positive or exaggerated response and completion of the protocol. If syncope occurred during the test, the patient was returned to a supine position and the test was discontinued.

Definitions
Syncope was defined as sudden, transient loss of consciousness with inability to maintain postural tone followed by spontaneous recovery. HUT was considered positive when syncope was reproduced in association with hypotension (decrease in systolic blood pressure >60% of the maximal value observed in the upright position), bradycardia (decrease >30% of the maximal value observed in the upright position), or both.26,28 Positive responses were classified according to the new VASIS classification:34 type 1 (mixed), types 2A (cardioinhibitory without asystole) and 2B (cardioinhibitory with asystole), and type 3 (vasodepressor). An asystolic response was defined as the development of ventricular asystole of >3 s duration. Heart rate and blood pressure at the time of syncope were used to define positive responses.35 Exaggerated responses were defined during pharmacological phase as gradual development of symptoms, usually minor and different from the spontaneous ones, associated with a progressive and slow (occurring in>5 min) decrease in blood pressure alone, with only a slight reduction (<30%) or no reduction in heart rate.26,33 Time to syncope was defined as the interval from the beginning of upright position to the loss of consciousness.

Statistical analysis
Results are expressed as mean values ± standard deviation. Comparisons between the groups were made with Student's t-test for paired and unpaired parametric data, {chi}2 test and Fisher's exact test for categorical variables as appropriate, Mann–Whitney U-test for ordinal variables. Tests were two-sided. A P-value of <0.05 was considered statistically significant. All statistical analyses were performed using SPSS software (version 12.0, SPSS Inc., Chicago, IL, USA).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusions
 Funding
 References
 
In three patients (5, 9, and 14 years old, respectively), the test was not performed, because of psychomotor hyperactivity. Thus, 161 patients underwent sublingual NTG-potentiated HUT. The results of the test are summarized in Table 2. During the initial phase (unmedicated phase), 13 patients (8%) had syncope; 148 (92%) remained asymptomatic and underwent sublingual NTG administration. After drug stimulation, a positive response occurred in another 88 patients (55%), giving a 63% global positivity rate for the test; a negative response occurred in 51 patients (32%) and an exaggerated response in nine (5%). Considering only the pharmacological phase, among the 148 patients who were given sublingual NTG, we observed a percentage of positive, negative, and exaggerated response of 59, 34, and 6%, respectively. After NTG administration only three patients (2%) had side effects (light headache), which did not require test interruption.


View this table:
[in this window]
[in a new window]

  		Table 2 Results of head-up tilt testing potentiated with sublingual nitroglycerin

 
The mean time to syncope in paediatric patients with positive response was 14 ± 5 min (range 3–20, median 16 min) during the unmedicated phase and 5 ± 3 min (range 1–13, median 5 min) after NTG stimulation.

In Table 3, the types of positive response are shown according to new VASIS classification.34 Sixty-four patients (63%) had a mixed response, 31 patients (31%) had a cardioinhibitory response, and six patients (6%) had a vasodepressor response. Twenty-five patients (25%) with a positive cardioinhibitory response had an asystolic pause of >3 s with sinus arrest or third-degree atrioventricular block at the time syncope occurred. An asystolic response was observed in six of the 13 patients (46%) with a positive response during the unmedicated phase of the test and 19 of the 88 patients (22%) who had symptoms after NTG administration. The mean duration of asystolic pause was 7.3 ± 5.1 s (range 3–27.4, median 6 s).


View this table:
[in this window]
[in a new window]

  		Table 3 Pattern of positive response according to new VASIS classification

 
There were no significant differences in HUT outcomes with respect to the following patients' clinical variables: syncopal burden, duration of symptoms, and time between last syncope and HUT execution.

In the subgroup of 13 younger patients, aged up to 8 years (range 4–8), who underwent HUT, none had syncope during the unmedicated phase, nine (69%) had a positive response after NTG challenge, three (23%) had a negative response, and one (8%) had an exaggerated response. Thus, the positivity rate among very young patients was 69%.

Of 29 control children, none had syncope during the unmedicated phase of tilt testing, whereas four (14%) had a positive response after NTG administration. Four other control children (14%) had an exaggerated response after drug stimulation. The remaining 21 control children remained asymptomatic also after NTG administration (Table 2). Thus, the specificity of NTG-potentiated HUT was 86%. Among positive responses, three children (75%) had a mixed response, whereas only one (25%) had a cardioinhibitory response, with an asystole of 3 s (Table 3).

In the subgroup of seven younger control children up to 8 years old (range 5–8), only one child (14%) had a positive HUT after NTG administration. Thus, the specificity of the test among very young children was 86%.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusions
 Funding
 References
 
NTG-potentiated tilt testing has been extensively studied in adults.26–29 In this study, a protocol of HUT potentiated with sublingual NTG33 has been evaluated in paediatric patients, showing a positivity rate of 63% and a specificity of 86%. In our study, the positivity rate of the passive phase was low (8%), whereas in previous works in children it ranged from 10.7 to 65%.12–22,30 This wide range of results appears to be due to the great differences in the test protocols, regarding both the degree of tilt table inclination (from 60° to 90°) and the duration of the test (from 10 to 60 min). Also intravenous cannulation may have influenced the results of passive HUT, when utilized. Finally, the study populations were different in the various studies, particularly with respect to the age of children and their syncopal burden.

In our study, HUT positivity rate increased almost eight-folds (from 8 to 63%) after sublingual NTG administration. Our data are similar to those found with intravenous IPN potentiated HUT, which showed a positivity rate in children from 43 to 80%.12,15,17,19–22 Recently Dindar et al.30 found a positivity rate of 77.5%, utilizing a HUT protocol potentiated with sublingual isosorbide dinitrate in a population of 40 paediatric patients aged 9–18 years. Moreover, our positivity rate of NTG-potentiated HUT in children is similar to adults, where it ranges from 51 to 78%.33

In our study, among children with positive NTG-potentiated HUT and according to new VASIS classification, the mixed response was prevalent (63%). Utilizing IPN-stimulated HUT, Pongiglione et al.12 found a prevalence of mixed response of 63% in children, whereas in two other studies,20,21 it was prevalent the vasodepressor response (68 and 52%, respectively). Our results are similar to what we found in adults, where the mixed response was present in 60% of positive NTG-potentiated tilt testing.27 Interestingly, among children there was a quite high prevalence of asystolic response (25%), particularly for those patients who had syncope during the drug-free phase (46%). In previous studies in children, asystolic response ranged from 15 to 50%.12,14,18,20–22 In adults Raviele et al.26 found a prevalence of asystolic response of 17% in positive NTG-potentiated HUT.

A critical point is HUT specificity in children. In our study, none of 29 controls fainted during the passive phase; thus, the specificity of passive tilt testing was 100%. In previous studies, the specificity of HUT passive phase varied from 48 to 100%.14,16,17,23–25,30 Specificity was high in those studies which did not include intravenous incannulation,14,16,25,30 ranging from 83 to 100%; on the contrary, it was quite poor in those protocols which included intravascular instrumentation,17,23,24 ranging from 48 to 65%. Indeed, it was observed that the use of tilt testing in combination with intravascular instrumentation heavily affects the specificity of the test, rising serious doubts about its utility in evaluating syncope of unknown origin in children.23,25 In our study after sublingual NTG administration, four of 29 controls had syncope, with a test specificity of 86%. Our finding is similar to what observed in the single work which assessed the specificity of IPN-potentiated HUT: in fact, Alehan et al.21 found a specificity of 87% in a control group of 15 healthy children. However, sublingual NTG test appears to be timesaving and better tolerated, avoiding intravascular instrumentation, to which children usually manifest great levels of anxiety.24 Recently Dindar et al.30 reported a specificity of 91.6%, utilizing sublingual isosorbide dinitrate in 12 healthy children. Again, our protocol, utilizing a fixed dose of spray sublingual NTG, seems to be simpler than the protocol proposed by Dindar et al., which utilized isosorbide dinitrate at a body weight adjusted dose.

Another fact that could affect HUT specificity is represented by the high incidence of neurally mediated syncope in children.7,24 A ‘false positive’ response in a control paediatric subject could represent a real susceptibility to clinical neurally mediated syncope, which might spontaneously occur later in lifetime. Indeed, anecdotically, one out of four control subjects with positive HUT experienced spontaneous syncope 6 months after undergoing the test.

In our study, nine patients (5%) and four control subjects (14%) had exaggerated response. This result is similar to that found by Del Rosso et al.28 in adults. Exaggerated response has been widely described in previous studies evaluating NTG-potentiated HUT,26–28,33,34 whereas it has not been observed during passive phase of HUT or after IPN administration, either in adults or in children. The diagnostic value of this response is still uncertain. It has been hypothesized that it could be due to an excessive vasodilatation produced by NTG.26–28 Alternatively, exaggerated response could be expression of a dysautonomic pattern, particularly in elderly patients.34 In our opinion, in a paediatric population it might be due to an excessive drug-induced vasodilatation. Anyhow exaggerated response is not regarded as expression of a vasovagal reflex.26–28,33,34 Thus, we considered exaggerated response a non-specific result, as previously proposed.26–28

Noteworthy, we performed sublingual NTG-potentiated HUT also in very young children, both patients and controls subjects. In this subgroup of children aged 8 or less, NTG-potentiated tilt testing proved to be feasible and well tolerated, with a similar positivity rate and specificity to older children.

In our study, sublingual NTG HUT was safe and well tolerated. In fact, after NTG administration, in only three patients (2%) the test was complicated by headache, which nevertheless did not request test interruption.


   Conclusions
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
Funding
 References
 
Tilt testing potentiated with sublingual NTG is a quite sensitive and specific diagnostic tool for the work up of syncope in children. It yields similar results to the IPN test, but it is easier to perform and avoids venous puncture, which may affect the test specificity. Thus, it could be proposed as first-line test in evaluating unexplained syncope in children.

Conflict of interest: none declared.


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Funding
References
 


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Funding
 References
 

  1. Ruckman RN. Cardiac causes of syncope. Paediatric Rev (1987) 9:101–108.[CrossRef]
  2. Driscoll DJ, Jacobsen SJ, Porter CJ, Wollan PC. Syncope in children and adolescents. J Am Coll Cardiol (1997) 29:1039–1045.[Abstract]
  3. Tanel RE, Walsh EP. Syncope in the pediatric patient. Cardiol Clin (1997) 15:277–294.[Medline]
  4. Pratt JL, Fleisher GR. Syncope in children and adolescents. Pediatr Emerg Care (1989) 5:80.[Medline]
  5. Ozme S, Alehan D, Yalaz K, Cakir S, Celiker A Ozer S. Causes of syncope in children: a prospective study. Int J Cardiol (1993) 40:111–114.[CrossRef][Web of Science][Medline]
  6. Massin MM, Bourguignont A, Coremans C, Comte L, Lepage P, Gerard P. Syncope in pediatric patients presenting to an emergency department. J Pediatr (2004) 145:223–228.[CrossRef][Web of Science][Medline]
  7. Wieling W, Ganzeboom KS, Saul JP. Reflex syncope in children and adolescents. Heart (2004) 90:1094–1100.[Free Full Text]
  8. Hannon D, Ross BA. Head up tilt testing in children who faint. J Pediatr (1991) 118:731–732.[CrossRef][Web of Science][Medline]
  9. Strieper MJ, Auld DO, Huls JE, Campbell RM. Evaluation of recurrent pediatric syncope: role of tilt table testing. Pediatrics (1994) 93:660–662.[Abstract/Free Full Text]
  10. Steinberg LA, Knilans TK. Syncope in children: diagnostic tests have a high cost and low yield. J Pediatr (2005) 146:355–358.[CrossRef][Web of Science][Medline]
  11. Seifer CM, Kenny RA. Head-up tilt testing in children. Eur Heart J (2001) 22:1968–1971.[Free Full Text]
  12. Pongiglione G, Fish F, Strasburger J, Benson W. Heart rate and blood pressure response to upright tilt in young patients with unexplained syncope. J Am Coll Cardiol (1990) 16:165–170.[Abstract]
  13. Thilenius OG, Quinones JA, Husayni TS, Novak J. Tilt test for diagnosis of unexplained syncope in pediatric patients. Pediatrics (1991) 87:334–338.[Abstract/Free Full Text]
  14. Lerman-Sagie T, Rechavia E, Strasberg B, Sagie A, Blieden L, Mimouni M. Head-up tilt for the evaluation of syncope of unknown origin in children. J Pediatr (1991) 118:676–679.[CrossRef][Web of Science][Medline]
  15. Grubb BP, Temesy-Armos P, Moore J, Wolfe D, Hahn H, Elliott L. The use of head-upright tilt table testing in the evaluation and management of syncope in children and adolescents. Pacing Clin Electrophysiol (1992) 15:742–748.[Medline]
  16. Fouad FM, Sitthisook S, Vanerio G, Maloney J III, Okabe M, Jaeger F, Schluchter M, Maloney JD. Sensitivity and specificity of the tilt table test in young patients with unexplained syncope. Pacing Clin Electrophysiol (1993) 16:394–400.[CrossRef][Medline]
  17. Berkowitz JB, Auld D, Hulse JE, Campbell RM. Tilt table evaluation for control pediatric patients: comparison with symptomatic patients. Clin Cardiol (1995) 18:521–525.[Web of Science][Medline]
  18. Pollini I, Favilli S, De Simon L, Romanelli AM, Manetti A. Syncope at pediatric ages: evaluation with head-up tilt. Cardiologia (1998) 43:499–503.[Medline]
  19. O'Marcaigh AS, MacLellan-Tobert SG, Porter CJ. Tilt-table testing and oral metoprolol therapy in young patients with unexplained syncope. Pediatrics (1994) 93:278–283.[Abstract/Free Full Text]
  20. Kouakam C, Vaksmann G, Lacroix D, Godart F, Kacet S, Rey C. Value of the tilt test in the management of unexplained syncope in children and adolescents. Arch Mal Coeur (1997) 90:679–686.[Medline]
  21. Alehan D, Lenk M, Ozme S, Celiker A, Ozer S. Comparison of sensitivity and specificity of tilt protocols with and without isoproterenol in children with unexplained syncope. Pacing Clin Electrophysiol (1997) 20:1769–1776.[CrossRef][Medline]
  22. Mangru NN, Young ML, Mas MS, Chandar JS, Pearse LA, Wolff GS. Usefulness of tilt table test with normal saline infusion in management of neurocardiogenic syncope in children. Am Heart J (1996) 131:953–955.[CrossRef][Web of Science][Medline]
  23. Van Steenwijk CCE, Wieling W, Johannes JM, Harms MP, Kuis W, Wesseling KH. Incidence and hemodynamic characteristics of near-fainting in healthy 6 to 16 year old subjects. J Am Coll Cardiol (1995) 25:1615–1621.[Abstract]
  24. Lewis DA, Zlotocha J, Henke L, Dhala A. Specificity of head-up tilt testing in adolescents: effect of various degrees of tilt challenge in normal control subjects. J Am Coll Cardiol (1997) 30:1057–1060.[Abstract]
  25. Sung RY, Yu CW, Ng E, Du ZD, Tomlinson B, Tam MS. Head-up tilt test without intravascular cannulation in children and adolescents. Int J Cardiol (2001) 89:69–76.
  26. Raviele A, Menozzi C, Brignole M, Gasparini G, Alboni P, Musso G, Lolli G, Oddone D, Dinelli M, Mureddu R. Value of head-up tilt testing potentiated with sublingual nitroglycerin to assess the origin of unexplained syncope. Am J Cardiol (1995) 76:267–272.[CrossRef][Web of Science][Medline]
  27. Foglia-Manzillo G, Giada F, Beretta S, Corrado G, Santarone M, Raviele A. Reproducibility of head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope. Am J Cardiol (1999) 84:284–288.[CrossRef][Web of Science][Medline]
  28. Del Rosso A, Bartoletti A, Bartoli P, Ungar A, Bonechi F, Maioli M, Ieri A. Methodology of head-up tilt testing potentiated with sublingual nitroglycerin in unexplained syncope. Am J Cardiol (2000) 85:1007–1011.[CrossRef][Web of Science][Medline]
  29. Raviele A, Giada F, Brignole M, Menozzi C, Marangoni E, Foglia-Manzillo G, Alboni P. Comparison of diagnostic accuracy of sublingual nitroglycerin test and low dose isoprenaline test in patients with unexplained syncope. Am J Cardiol (2000) 5:1194–1198.
  30. Dindar A, Cetin B, Ertrugul T, Cantez T. Sublingual isosorbide dinitrate-stimulated tilt test for diagnosis of vasovagal syncope in children and adolescents. Pediatr Cardiol (2003) 24:270–273.[CrossRef][Web of Science][Medline]
  31. Petersen MEV, Williams TR, Sutton R. A comparison of non-invasive continuous finger blood pressure measurement (Finapres) with intra-arterial pressure during prolonged head-up tilt. Eur Heart J (1995) 16:1647–1654.[Abstract/Free Full Text]
  32. Tanaka H, Thulesius O, Yamaguchi J, Mino M, Konishi K. Continuous non-invasive finger blood pressure monitoring in children. Acta Pediatr (1994) 83:646–652.[Web of Science][Medline]
  33. Bartoletti A, Alboni, Ammirati F, Brignole M, Del Rosso A, Foglia-Manzillo G, Menozzi C, Raviele A, Sutton R. ‘The Italian Protocol’: a simplified head-up tilt testing potentiated with oral nitroglycerin to assess patients with unexplained syncope. Europace (2000) 2:339–342.[Abstract/Free Full Text]
  34. Brignole M, Menozzi C, Del Rosso A, Costa S, Gaggioli G, Bottoni N, Bartoli P, Sutton R. New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification. Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study. Europace (2000) 1:66–76.
  35. Del Rosso A, Bartoletti A. Nitrate-stimulated test. (Letter). Am Heart J (1999) 137:575–576.[Web of Science][Medline]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Eur Heart JHome page
G. Foglia-Manzillo and F. Giada
Tilt testing potentiated with sublingual nitroglycerin in children with unexplained syncope: reply
Eur. Heart J., April 2, 2008; 29(8): 1075 - 1075.
[Full Text] [PDF]

Home page
 Eur Heart JHome page
E. Jastrzebska-Maj, K. Mizia-Stec, and D. Jakubowski
Tilt testing potentiated with sublingual nitroglycerin in children with unexplained syncope
Eur. Heart J., April 2, 2008; 29(8): 1074 - 1075.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
28/21/2605    most recent
ehm430v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Foglia-Manzillo, G.
Right arrow Articles by Raviele, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Foglia-Manzillo, G.
Right arrow Articles by Raviele, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?