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It's Just a Tilt Table Test.........

Today started out like any other day……..

I woke up with a raging headache, numbness, blurred vision, burning in my nerves and soreness along the left side of my body. As I rolled out of bed and my feet hit the floor the nerves on the bottom of my feet decided to revolt and elicited a nice jolt of morning pain. My body responded to my request for movement with an immediate drop in blood pressure adding dizziness and nausea to the list of discomforts.

I pulled myself together got dressed and ready to go to the hospital for a tilt table test. I have never had this test done and didn't think much of it. After all, having had a million tests done in the last several years I have learned, as many of you probably have, to endure discomfort.

So what's the big deal about a tilt table test? Well, if you don't suffer from Orthostatic Intolerance or Neurally Mediated Hypotension it's not likely to be a big deal, but if you do you are in for one hell of a day!

What's Neurally Mediated Hypotension (NMH), you ask? Neurally Mediated Hypotension, also known as neurocardiogenic syncope, vasodepressor syncope, the vaso-vagal reflex, the fainting reflex, orthostatic intolerance and autonomic dysfunction, is a condition which involves miscommunication between the heart and the brain. And it happens when there is an abnormal reflex interaction between the heart and the brain.

Dr Peter Rowe, one of the members of the Johns Hopkins University research team, says: "We think that in these patients, the heart is generally normal and the brain is normal, but the reflex interaction between the two is what is out of kilter. And what seems to trigger that dysfunction is a state of a low amount of blood in the ventricle of the heart while standing. It is either low because you've started with a lesser volume of blood, for whatever reason, or because the amount of effective blood volume that is potentially available is not getting delivered to the heart because of an excessive amount of pooling in the extremities." Basically it is a malfunction of the nervous system, specifically the autonomic nervous system, your bodies' auto-pilot.

To better understand this phenomenon, we must first examine how the nervous system in our bodies functions. "During our daily activities, our heart rate (HR) and blood pressure (BP) constantly rise and fall to meet the needs of the body. The HR and BP are lower at rest, while the HR picks up and BP is elevated during emotional stress and exercise. The control of the HR and BP are under the domain of the sympathetic and parasympathetic nervous system (2 of the 3 parts of the autonomic nervous system). The former increases the HR and BP while the latter reduces them. To simplify this concept, let us imagine that the body is an automobile. Pressing the accelerator pedal would make the car work harder and go faster. In contrast, pressing the brake pedal would slow the car down. Thus, the sympathetic nervous system behaves like an accelerator for the body while the parasympathetic system functions like a braking system. You with me so far? Great!

Normally, the sympathetic and parasympathetic nervous systems work together in a very efficient and cooperative manner. Just like a good driver, the accelerator and brake pedals are used efficiently (one being slowly pressed while the other is smoothly released). The car slows down and speeds up so smoothly that one does not recognize the change. Similarly, our HR and BP go up and down without us being aware of it. From time to time, this system breaks down in people with NMH. It is almost as if the accelerator pedal remains in the control of the car driver while the braking system is occasionally turned over to an extremely nervous "back seat driver." This spells trouble! Now, if the "car" accelerates too rapidly (HR and BP goes up), the back seat driver panics and SLAMS the brake. The HR and BP (either singly or together) drop suddenly and severely. This reduces blood supply to the brain and the patient passes out. The back seat driver then steps off the brake pedal, the HR and BP increase, blood flow is restored, and the patient awakens." Theoretically when your body returns to a horizontal position and the blood pressure returns to normal your symptoms are alleviated. Mind you, this is theoretically and certainly not in my case!

So how is the Tilt Test Performed?

Heartsite.com says it better than I can……

"The patient is hooked to an EKG machine and a BP monitor. The HR and BP are constantly monitored during the procedure. An intravenous (IV) line is placed in the arm. Large patches are also applied to the patient's chest.

These patches are connected to an external pacemaker and turned on if the patient's HR slows down and does not pick right up (in the majority of cases the slow HR is transient and the external pacemaker is only a precautionary measure).

The patient lays on a swivel table in a flat position. Safety straps are applied across the chest and legs to hold the patient in place.

After obtaining the baseline HR and BP, the motorized table is tilted up to an angle of 80 degrees. This simulates going from a flat (supine) to a standing or upright position. The change in position causes the HR and BP to rise and the patient's response is noted. Depending upon the physician and the protocol of a given laboratory, the duration of time spent in the supine and upright position can vary from 5 to 30 minutes.

If nothing happens, the table is returned to the flat position and an intravenous infusion of isoproternol (Trade name = Isuprel) is started. This medicine increases the HR and BP. This effect is similar to that produced by our own natural adrenaline release. As you may have gathered, the test is now simulating what happens when the sympathetic nervous system is stimulated and the "accelerator" is pressed. The tilt table is then raised back up to 80 degrees and the IV medication continued.

A stop clock in the room is used to keep track of time. If an abnormal result is not seen, the table is lowered and then raised back up after increasing the dose of the IV medicine. In patients with NMS, the increase in HR and BP is usually sufficient to cause "panic in the back seat driver" (parasympathetic nervous system). When this happens, the HR, BP or both drop suddenly and dramatically as the parasympathetic system "slams the brake pedal.". The patient gets dizzy and passes out. Thus, TTT succeeds in simulating a real life situation and establishes the cause of recurrent black out spells. With the above changes, the test is considered positive. The IV medicine is immediately stopped and the patient returned to the flat or supine position. Within a few seconds, the patient regains consciousness and both the HR and BP return to normal. The patient is observed for 10 to 20 minutes and then disconnected from the equipment."

Sounds easy enough, unless you have NMH! If the test is positive and causes a black out spell, it is certainly not a very pleasant circumstance! Sure it's nice to have a definitive diagnosis, but boy it is not fun.

I don't tend to easily pass out, my body fights and fights hard to keep from passing out. During the tilt table test you are strapped down so when you are placed in an up right position you cannot move your legs or bend your knees. And for me, moving my legs is one of the little techniques I have always used to keep my symptoms from progressing too far.

So, flash back to my test today:

I was placed in a freezing cold room and plugged into a zillion pieces of fancy equipment, all meant to let the doctors know that you are still alive. I had 3 straps holding me to a table preventing me from moving my legs or mid section. I had an I.V. in one arm and a blood pressure cuff on the other arm. In the beginning I wasn't that uncomfortable, I have learned over the years to deal with times such as this by finding a peaceful place within myself and relax into my version of meditating.

So, the test started without much discomfort at first, but it fast escalated into a full out fight or flight experience! Once the doctor administered the medication to increase my heart rate and placed the table in an upright position my body immediately responded with an extreme drop in blood pressure and my heart rate sky rocketed. The room began to spin and I thought for certain that I was going to projectile vomit all over the room and the doctors! I began to panic and tried desperately to get my legs free from the straps to rescue myself. I completely forgot where I was and what was happening and all I could think about was getting free. I felt violently ill and I think it would probably had been better if I had just passed out, but my instinct and the nature of my body wouldn't let me, so I simply suffered through the experience for what I felt was an eternity.

I finally ended up begging the doctor for mercy and he agreed to lower the table since, as he stated, he had already arrived at a positive diagnosis and that my blood pressure had plummeted to near ZERO! He said, "I'm sure that wasn't comfortable". Wasn't comfortable? He said near ZERO! No wonder I felt so horrible. I felt I was near death!

Once the doctor put me back in a horizontal position I have to admit I did feel a lot better, still like crap but no longer at death's door. The test left me with a new myriad of neurological and cardiovascular symptoms that have yet to diminish. But, trust me, none of it compares to how awful I felt during the test, it certainly reminds me that everything is relative!

Oh well, tomorrow is another day…. And it will start out like any other day.