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Robert S. Sheldon - One of the best experts on this subject based on the ideXlab platform.
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Timing of First Recurrence of Syncope Predicts Syncopal Frequency After a Positive Tilt Table Test Result
Journal of the American College of Cardiology, 1997Co-Authors: Malik P, Mary Lou Koshman, Robert S. SheldonAbstract:Abstract Objectives. This study sought to determine whether the time to first recurrence of syncope after a positive isoproterenol–Tilt Table Test result accurately predicts the eventual frequency of syncope. Background. Both patient care and future clinical trials involving patients with neuromediated syncope will require a simple measure that reflects the frequency of syncope. The time from Tilt Table Testing to the first recurrence of syncope might be such a measure. Methods. A cohort of 46 patients with syncope, in a university outpatient clinic, who had at least one syncopal spell after a positive isoproterenol–Tilt Table Test result were followed up for up to 6.5 years (mean [±SD] 48 ± 14 months). The time from Tilt Table Testing to the first recurrence of syncope was correlated. Results. A total of 40 of 46 patients had more than one recurrent spell, with a median of eight recurrent spells. The time to the first syncopal spell predicted the frequency of spells with r = −0.79 (p Conclusions. The time to the first recurrent spell predicts the frequency of syncopal spells after a positive Tilt Table Test result, and the instantaneous risk of syncope is constant. (J Am Coll Cardiol 1997;29:1284–9)
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risk factors for syncope recurrence after a positive Tilt Table Test in patients with syncope
Circulation, 1996Co-Authors: Robert S. Sheldon, Mary Lou Koshman, Sarah Rose, Patricia Flanagan, Shawn KillamAbstract:Background Recent work with head-up Tilt-Table Testing has suggested that many patients with syncope may have recurrent neurally mediated episodes of bradycardia, hypotension, or both. The purpose of this study was to determine how to identify patients at high risk of a recurrence of neuromediated syncope after a positive isoproterenol/Tilt-Table Test. Methods and Results A cohort of 101 drug-free patients in a university hospital outpatient clinic with syncope and a positive isoproterenol/Tilt-Table Test underwent baseline assessment of demographic variables, symptomatic burden, and hemodynamic and clinical responses to Tilt Testing. The primary outcome measure was the time to the first recurrent syncopal spell. The actuarial probabilities of remaining syncope free after 1 and 2 years were 72% and 60%, respectively. Multivariate proportional hazards analysis demonstrated that the most powerful predictor of a recurrence of syncope was the logarithm of the number of preceding syncopal spells (P<.001). Othe...
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Isoproterenol Tilt-Table Testing in patients with syncope and structural heart disease.
The American Journal of Cardiology, 1996Co-Authors: Robert S. Sheldon, Sarah Rose, Mary Lou KoshmanAbstract:We studied 55 patients with syncope and structural heart disease using both Tilt-Table Testing and electrophysiologic studies. Although sustained ventricular tachycardia was found in 21 of 55 patients (38%), and neuromediated syncope in 18 of 51 patients (35%), only 16% of patients with ventricular tachycardia had a positive Tilt-Table Test.
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evaluation of a single stage isoproterenol Tilt Table Test in patients with syncope
Journal of the American College of Cardiology, 1993Co-Authors: Robert S. SheldonAbstract:Objectives. The purpose of this study was to compare clinical outcomes and Tilt Test variables between a single-stage Tilt Test with an infusion of 5 μg/min of isoproterenol and a conventional multistage Test with infusions of 0, 2 and 5 μg/min of isoproterenol in three successive stages. Background. The diagnosis of neuromediated syncope is often established with isoproterenol-head-up Tilt Table Testing. Previous work has suggested that a single infusion of 5 μg/min of isoproterenol during 80 ° head-up Tilt for ≤ 10 min should be sufficient to establish the diagnosis. Methods. Forty patients with recurrent syncope underwent both Tests in a randomized crossover fashion. Results. Of 24 patients with positive findings on a multistage Test, 19 (79%) had positive findings on a single-stage Test, whereas 13 (81%) of 16 patients with negative results on a multistage Test had negative results on a single-stage Test (p < 0.001, chi-square analysis). Presyncope developed monoexponentially with time at similar rates in both Tests, with half-times to presyncope of 1.3 and 2 min for the single-stage and multistage Test, respectively. InterTest intrapatient times to presyncope correlated well (r = 0.74, p = 0.001). Finally, peak and trough heart rates each were similar and correlated well between Tests. The mean peak heart rate was 136 ± 25 and 133 ± 18 beats/min for the single-stage and multistage Test, respectively (p = NS, tTest; r = 0.50, p = 0.002, linear regression). The mean trough heart rate was 76 ± 31 and 78 ± 36 beats/min for the single-stage and multistage Test, respectively (p = NS, fTest; r = 0.86, p < 0.001, linear regression analysis). Conclusions. The single-stage and multistage Tilt Tests are equivalent with regard to clinical outcome and Tilt Test variables, although the single-stage Test is considerably less time-consuming.
O H Teixeira - One of the best experts on this subject based on the ideXlab platform.
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cerebral blood flow velocity during Tilt Table Test for pediatric syncope
Pediatrics, 1999Co-Authors: R A Rodriguez, K Snider, G Cornel, O H TeixeiraAbstract:BACKGROUND Brain hypoperfusion during neurocardiogenic syncope develops as a consequence of hypotension and bradycardia. Transcranial Doppler indicates that an increase in cerebral vascular resistance occurs before or during the loss of consciousness. OBJECTIVE Cerebral blood flow velocity was studied during Tilt Table Testing in pediatric patients with neurocardiogenic syncope. We assessed whether a critical reduction in flow velocity (>40%) was predictive of the presyncopal manifestations during the Test. METHODS A 2-MHz transcranial Doppler measured blood flow velocity in the right middle cerebral artery in 27 pediatric patients (ages, 8 to 18 years) during a three-stage 80 degrees Tilt Table Test protocol. A positive Test required development of syncope or presyncope with at least 30% decrease in systolic blood pressure and/or heart rate relative to preceding values. Patients were divided into: group I (isoproterenol-induced positive Tests), group II (positive without isoproterenol), and group III (negative Tests). RESULTS Within the first 3 minutes of the upright position mean cerebral blood flow velocity in groups I, II, and III decreased by 18%, 29%, and 17%, respectively, as the systolic and diastolic blood pressures showed only minimal changes. A decreased mean blood flow velocity of 48% and 45% and an increase in resistance index of 42% and 26% from supine values in the absence of hypotension, were detected in groups I and II at 46 seconds (range, 30-120 seconds) and 50 seconds (range, 0-300 seconds) before any clinical symptom (presyncope latency). Mean blood flow velocity during presyncope decreased by 58% and 59%, whereas resistance index was double. A significant correlation (rho = -0.62) was found between presyncope latency and the decreased mean cerebral blood flow velocity. Similar blood flow velocity changes were not detected in group III. CONCLUSION A sustained reduction >40% in mean cerebral blood flow velocity in the absence of hypotension always resulted in presyncopal or syncopal manifestations. It seems that once this critical threshold is identified during the Tilt Table Testing, supine position may be resumed several seconds before the clinical manifestations of syncope.
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Cerebral blood flow velocity during Tilt Table Test for pediatric syncope.
Pediatrics, 1999Co-Authors: R A Rodriguez, K Snider, G Cornel, O H TeixeiraAbstract:Brain hypoperfusion during neurocardiogenic syncope develops as a consequence of hypotension and bradycardia. Transcranial Doppler indicates that an increase in cerebral vascular resistance occurs before or during the loss of consciousness. Cerebral blood flow velocity was studied during Tilt Table Testing in pediatric patients with neurocardiogenic syncope. We assessed whether a critical reduction in flow velocity (>40%) was predictive of the presyncopal manifestations during the Test. A 2-MHz transcranial Doppler measured blood flow velocity in the right middle cerebral artery in 27 pediatric patients (ages, 8 to 18 years) during a three-stage 80 degrees Tilt Table Test protocol. A positive Test required development of syncope or presyncope with at least 30% decrease in systolic blood pressure and/or heart rate relative to preceding values. Patients were divided into: group I (isoproterenol-induced positive Tests), group II (positive without isoproterenol), and group III (negative Tests). Within the first 3 minutes of the upright position mean cerebral blood flow velocity in groups I, II, and III decreased by 18%, 29%, and 17%, respectively, as the systolic and diastolic blood pressures showed only minimal changes. A decreased mean blood flow velocity of 48% and 45% and an increase in resistance index of 42% and 26% from supine values in the absence of hypotension, were detected in groups I and II at 46 seconds (range, 30-120 seconds) and 50 seconds (range, 0-300 seconds) before any clinical symptom (presyncope latency). Mean blood flow velocity during presyncope decreased by 58% and 59%, whereas resistance index was double. A significant correlation (rho = -0.62) was found between presyncope latency and the decreased mean cerebral blood flow velocity. Similar blood flow velocity changes were not detected in group III. A sustained reduction >40% in mean cerebral blood flow velocity in the absence of hypotension always resulted in presyncopal or syncopal manifestations. It seems that once this critical threshold is identified during the Tilt Table Testing, supine position may be resumed several seconds before the clinical manifestations of syncope.
Ali Bozorg - One of the best experts on this subject based on the ideXlab platform.
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Tilt Table Test misdiagnosis of epilepsy p02 169
Neurology, 2012Co-Authors: Deepali Jain, Ali BozorgAbstract:Objective: To discuss four cases, where diagnosis of epilepsy was missed secondary to an “abnormal Tilt Table Test.” Background Although patho-physiologically distinct, syncope and seizures share clinical characteristics which may make diagnosis difficult. Syncope may be associated with seizure-like motor manifestations, and seizures may be complicated by cardiac arrhythmia and loss of consciousness. Over the last decade, upright Tilt Table Testing has emerged as an important diagnostic method for the identification of individuals whose syncope is likely to be neurocardiogenic in origin. Design/Methods: We studied all the patients referred to our epilepsy center for evaluation of loss of consciousness between ages 18 to 65 years. This included all outpatient referrals and direct admits to the video-EEG monitoring (VEEM) unit over one year. The diagnosis of epilepsy was made based on the presence of strong interictal EEG abnormalities, or ictal EEG abnormality correlating with the events to suggest the diagnosis of epilepsy. Results: We diagnosed four patients with epilepsy, who were previously diagnosed with syncope based on “abnormal Tilt-Table Test.” Two patients were diagnosed based on outpatient EEG, during which one patient had clinical and electrographic seizure and the other one had strong evidence of interictal generalized spikes. The remaining two patients had prolonged VEEM, and multiple events were captured, which confirmed the diagnosis of epilepsy. At present time, three out of four patients are seizures-free with appropriate antiepileptic drugs (AEDs), and one has improved dramatically with addition of AEDs. Conclusions: Although the vast majority of patients that neurologist encounters in day to day life with possible syncope truly suffer from syncope, a small fraction of them may have epilepsy. The correct diagnosis can often be made if emphasis is put on adequate history taking instead of overemphasis on unnecessary ancillary Testing. Disclosure: Dr. Jain has nothing to disclose. Dr. Bozorg has nothing to disclose.
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Tilt Table Test & Misdiagnosis of Epilepsy (P02.169)
Neurology, 2012Co-Authors: Deepali Jain, Ali BozorgAbstract:Objective: To discuss four cases, where diagnosis of epilepsy was missed secondary to an “abnormal Tilt Table Test.” Background Although patho-physiologically distinct, syncope and seizures share clinical characteristics which may make diagnosis difficult. Syncope may be associated with seizure-like motor manifestations, and seizures may be complicated by cardiac arrhythmia and loss of consciousness. Over the last decade, upright Tilt Table Testing has emerged as an important diagnostic method for the identification of individuals whose syncope is likely to be neurocardiogenic in origin. Design/Methods: We studied all the patients referred to our epilepsy center for evaluation of loss of consciousness between ages 18 to 65 years. This included all outpatient referrals and direct admits to the video-EEG monitoring (VEEM) unit over one year. The diagnosis of epilepsy was made based on the presence of strong interictal EEG abnormalities, or ictal EEG abnormality correlating with the events to suggest the diagnosis of epilepsy. Results: We diagnosed four patients with epilepsy, who were previously diagnosed with syncope based on “abnormal Tilt-Table Test.” Two patients were diagnosed based on outpatient EEG, during which one patient had clinical and electrographic seizure and the other one had strong evidence of interictal generalized spikes. The remaining two patients had prolonged VEEM, and multiple events were captured, which confirmed the diagnosis of epilepsy. At present time, three out of four patients are seizures-free with appropriate antiepileptic drugs (AEDs), and one has improved dramatically with addition of AEDs. Conclusions: Although the vast majority of patients that neurologist encounters in day to day life with possible syncope truly suffer from syncope, a small fraction of them may have epilepsy. The correct diagnosis can often be made if emphasis is put on adequate history taking instead of overemphasis on unnecessary ancillary Testing. Disclosure: Dr. Jain has nothing to disclose. Dr. Bozorg has nothing to disclose.
Mario Habek - One of the best experts on this subject based on the ideXlab platform.
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effect of food intake on hemodynamic parameters during the Tilt Table Test in patients with postural orthostatic tachycardia syndrome
Journal of Clinical Neurology, 2019Co-Authors: Mario Habek, Berislav Ruska, Luka Crnosija, Ivan Adamec, Anamari Junakovic, Magdalena Krbot SkoricAbstract:BACKGROUND AND PURPOSE The aim of this study was to determine the effect of food intake on the heart rate (HR) in postural orthostatic tachycardia syndrome (POTS). METHODS The following five-phase protocol was applied to 41 subjects who had a sustained HR increment of ≥30 beats/min within 10 min of standing in an initial Tilt-Table Test: 1) 10-min supine phase, 2) 10-min 70°-Tilted phase, 3) ingestion of 400 mL of Nutridrink Multi Fibre®, 4) 45-min supine phase, and 5) 10-min 70°-Tilted phase. Subjects were divided into four groups: A) difference in HR for standing vs. supine (ΔHR) before the meal of ≥30 beats/min (n=13), B) ΔHR <30 beats/min before the meal but ≥30 beats/min after the meal (n=12), and C) ΔHR <30 beats/min both before and after the meal (n=16). Group D consisted of 10 healthy subjects. RESULTS Before the meal, ΔHR was significantly higher in group A than in all of the other groups, and in group B than in group D (p<0.001). After the meal, ΔHR was significantly higher in groups A and B (p<0.001 and p<0.0001, respectively). When we pooled patients (according to their symptoms) from group A and B into a POTS group and from group C and D into a non-POTS group, an increase in HR of 25 beats/min before the meal had a sensitivity of 92.0% and a specificity of 80.8%. After the meal, an increase in HR of 30 beats/min had a sensitivity of 96.0% and a specificity of 96.2%. CONCLUSIONS Food intake can significantly alter the results of the Tilt-Table Test and so should be taken into account when diagnosing POTS.
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f54 food intake can significantly influence Tilt Table Test results in patients with postural orthostatic tachycardia syndrome
Clinical Neurophysiology, 2018Co-Authors: Luka Crnosija, Berislav Ruska, Ivan Adamec, Magdalena Krbot Skoric, Mario HabekAbstract:Introduction Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance characterized by excessive heart rate (HR) increase when in an upright posture, accompanied by characteristic symptoms such as lightheadedness, weakness, nausea, fatigue etc. Following criteria must be met when diagnosing POTS: (1) sustained heart rate (HR) increment of ⩾ 30 bpm within 10 min of standing or head-up Tilt in the absence of orthostatic hypotension; (2) a history of characteristic symptoms that are relieved by recumbency. Considering the known and significant impact a meal intake can have on autonomic nervous system activity, we aimed to investigate the effect of food intake on HR in patients with POTS. Methods Forty-one subjects who fulfilled POTS criteria on an initial Tilt Table Test performed the following protocol within the next 28 days: (1) 10-min supine phase, (2) 10-min 70° Tilted phase, (3) ingestion of 400 ml (616 kcal) of liquid meal replacement, (4) 45-min supine phase and (5) 10-min 70° Tilted phase. All the participants were fasting at least 3 h prior to the Testing. Subjects were divided into three groups: (A) difference ( Δ ) in HR (standing vs. supine) ⩾ 30 bpm before the meal (N = 13); (B) Δ HR ⩾ 30 bpm after the meal (N = 12); (C) Δ HR Results There were no significant differences in age and sex between the groups (p = 0.203 and p = 0.112). There were no differences in the supine HR and supine or Tilted systolic or diastolic blood pressure before or after the meal between groups (all p > 0.05). Before the meal, Δ HR was significantly higher in group A compared to all other groups, and in group B compared to group D (p Δ HR was significantly higher in group A compared to all other groups, and in group B compared to groups C and D (p Conclusion Food intake can significantly alter the results of the Tilt Table Test and should be taken into account when diagnosing POTS. Performing the Tilt-up Test after a controlled food intake may increase the Test quality (sensitivity and specificity), but this hypothesis should be Tested in a larger sample of patients and healthy subjects.
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association of autonomic nervous system abnormalities on head up Tilt Table Test with joint hypermobility
European Neurology, 2018Co-Authors: Ivan Adamec, Anamari Junakovic, Magdalena Krbot Skoric, Mario HabekAbstract:AIM: The aim of this study was to investigate the association of autonomic nervous system abnormalities on head-up Tilt Table Test (HUTT) with generalized joint hypermobility, expressed by Beighton score (BS). METHODS: This was a prospective study that included 115 consecutive patients (91 females ; mean age 34.35 ± 14.11) referred either for the HUTT or Testing of the cardiovascular autonomic reflexes together with HUTT. Generalized joint hypermobility was evaluated according to the BS system after which HUTT was performed. Clinically significant BS was considered if ≥4. RESULTS: Fifteen patients (15.1%) had BS ≥4. Results of the HUTT were normal in 58 (50.4%) patients and in 57 (49.6%) patient HUTT was abnormal. Fifteen (13.0%) patients fulfilled criteria for orthostatic hypotension, 30 (26.1%) for reflex syncope and 21 (18.3%) for postural orthostatic tachycardia syndrome. Patients with pathological findings on HUTT had significantly higher BS compared to patients with normal HUTT (median 1 vs. 0, p = 0.001). There was a significant association between participants with BS ≥4 and pathological HUTT (χ[1] = 6.392, p = 0.011). Results of the multivariate regression analysis revealed that increase in the BS is associated with the increased likelihood of HUTT pathology (Exp[B] 1.44, 95% CI 1.084-1.922, p = 0.012), while increase in age is associated with lower risk of HUTT pathology (Exp[B] 0.968, 95% CI 0.939-0.998, p = 0.036). CONCLUSION: There is an association between autonomic nervous system abnormalities on HUTT Test and generalized joint hypermobility.
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id 5 head up Tilt Table Test in differentiating neuropathic from hyperadrenergic type of postural orthostatic tachycardia syndrome pots
Clinical Neurophysiology, 2016Co-Authors: Luka Crnosija, Ivan Adamec, Anamari Junakovic, Krbot M Skoric, A Mismas, V Miletic, R Sprljanalfirev, Antun Pavelic, M Lovric, Mario HabekAbstract:Objective to investigate differences between hyperadrenergic and neuropathic type of POTS in cardiovascular response to orthostatic provocation. Methods Forty-three POTS patients underwent head-up Tilt Table Test (HUTT) protocol: 10-minute supine phase and 30-minute 70° Tilted phase. Serum catecholamine levels were determined and patients were categorized into one of two types of POTS. Results Ten patients had hyperadrenergic (group 1) and 33 had neuropathic (group 2) type of POTS. In group 1, 80% of the patients were men, and in group 2, 69.7% were women (p = 0.005). Group 1 had higer values of heart rate during supine phase (82.6 ± 16.3 bpm vs. 73.8 ± 10.4 bpm, p = 0.048). Group 2 had earlier Tilted phase mean ending time (8.8 ± 6.8 min vs. 21.2 ± 4.5 min, p = 0.001) as well as lower values of diastolic blood pressure difference between 1st minute of Tilted phase and supine values (−1.7 ± 7 mmHg vs. 5.6 ± 7.5 mmHg, p = 0.007). Using observed differences in response to orthostatic provocation we developed a HUTT model for differentiating neuropathic POTS with sensitivity of 76% and specificity of 80%. Conclusion Prolonged HUTT can differentiate between two types of POTS. Key message This study provides evidence that prolonged HUTT is valuable in making diagnostic and treatment decisions in POTS.
R A Rodriguez - One of the best experts on this subject based on the ideXlab platform.
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cerebral blood flow velocity during Tilt Table Test for pediatric syncope
Pediatrics, 1999Co-Authors: R A Rodriguez, K Snider, G Cornel, O H TeixeiraAbstract:BACKGROUND Brain hypoperfusion during neurocardiogenic syncope develops as a consequence of hypotension and bradycardia. Transcranial Doppler indicates that an increase in cerebral vascular resistance occurs before or during the loss of consciousness. OBJECTIVE Cerebral blood flow velocity was studied during Tilt Table Testing in pediatric patients with neurocardiogenic syncope. We assessed whether a critical reduction in flow velocity (>40%) was predictive of the presyncopal manifestations during the Test. METHODS A 2-MHz transcranial Doppler measured blood flow velocity in the right middle cerebral artery in 27 pediatric patients (ages, 8 to 18 years) during a three-stage 80 degrees Tilt Table Test protocol. A positive Test required development of syncope or presyncope with at least 30% decrease in systolic blood pressure and/or heart rate relative to preceding values. Patients were divided into: group I (isoproterenol-induced positive Tests), group II (positive without isoproterenol), and group III (negative Tests). RESULTS Within the first 3 minutes of the upright position mean cerebral blood flow velocity in groups I, II, and III decreased by 18%, 29%, and 17%, respectively, as the systolic and diastolic blood pressures showed only minimal changes. A decreased mean blood flow velocity of 48% and 45% and an increase in resistance index of 42% and 26% from supine values in the absence of hypotension, were detected in groups I and II at 46 seconds (range, 30-120 seconds) and 50 seconds (range, 0-300 seconds) before any clinical symptom (presyncope latency). Mean blood flow velocity during presyncope decreased by 58% and 59%, whereas resistance index was double. A significant correlation (rho = -0.62) was found between presyncope latency and the decreased mean cerebral blood flow velocity. Similar blood flow velocity changes were not detected in group III. CONCLUSION A sustained reduction >40% in mean cerebral blood flow velocity in the absence of hypotension always resulted in presyncopal or syncopal manifestations. It seems that once this critical threshold is identified during the Tilt Table Testing, supine position may be resumed several seconds before the clinical manifestations of syncope.
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Cerebral blood flow velocity during Tilt Table Test for pediatric syncope.
Pediatrics, 1999Co-Authors: R A Rodriguez, K Snider, G Cornel, O H TeixeiraAbstract:Brain hypoperfusion during neurocardiogenic syncope develops as a consequence of hypotension and bradycardia. Transcranial Doppler indicates that an increase in cerebral vascular resistance occurs before or during the loss of consciousness. Cerebral blood flow velocity was studied during Tilt Table Testing in pediatric patients with neurocardiogenic syncope. We assessed whether a critical reduction in flow velocity (>40%) was predictive of the presyncopal manifestations during the Test. A 2-MHz transcranial Doppler measured blood flow velocity in the right middle cerebral artery in 27 pediatric patients (ages, 8 to 18 years) during a three-stage 80 degrees Tilt Table Test protocol. A positive Test required development of syncope or presyncope with at least 30% decrease in systolic blood pressure and/or heart rate relative to preceding values. Patients were divided into: group I (isoproterenol-induced positive Tests), group II (positive without isoproterenol), and group III (negative Tests). Within the first 3 minutes of the upright position mean cerebral blood flow velocity in groups I, II, and III decreased by 18%, 29%, and 17%, respectively, as the systolic and diastolic blood pressures showed only minimal changes. A decreased mean blood flow velocity of 48% and 45% and an increase in resistance index of 42% and 26% from supine values in the absence of hypotension, were detected in groups I and II at 46 seconds (range, 30-120 seconds) and 50 seconds (range, 0-300 seconds) before any clinical symptom (presyncope latency). Mean blood flow velocity during presyncope decreased by 58% and 59%, whereas resistance index was double. A significant correlation (rho = -0.62) was found between presyncope latency and the decreased mean cerebral blood flow velocity. Similar blood flow velocity changes were not detected in group III. A sustained reduction >40% in mean cerebral blood flow velocity in the absence of hypotension always resulted in presyncopal or syncopal manifestations. It seems that once this critical threshold is identified during the Tilt Table Testing, supine position may be resumed several seconds before the clinical manifestations of syncope.