Tilt training averts syncope

A two-part tilt training programme designed to retrain the autonomic nervous system (ANS) to respond correctly to move to an upright position effectively prevented reflex syncope (RS) or fainting episodes, offering patients an improved quality of life (QoL) and ability to return to work, according to data presented at EHRA 2019.

A total of 102 individuals (mean age 46.13 years, 57.8 percent female) who had orthostatic-induced RS participated in the programme. The hospital sessions had participants lying on a table moving up to 60° (six sessions) and 70° (three sessions) – each time staying raised for 20–30 minutes. The sessions were spread across 3 weeks and repeated for another run after a 1-month interval. The daily home orthostatic self-training protocol required participants to sit up in bed at 60–70° for 30 minutes, tilt the head at 10° while sleeping, avoid rapid upright movements, drink about 2.5 litres of water, and perform 30-minute aerobic routines. Participants were examined at 1 month and every 6 months thereafter. [EHRA 2019, abstract P1096]

At 5.5 years, majority of the participants did not have recurrent episodes of syncope (86 percent) or presyncope (ie, feeling faint; 80 percent).

The remaining 14 percent either had a substantial decrease in the number of syncopal (1.4 vs 5.1 [baseline]/patient/year; p=0.0059) and presyncopal episodes post-tilt training compared with baseline (4.5 vs 11.4/patient/year; p=0.0175).

“Our study included teachers who fainted in the classroom and had to quit work,” said study author Dr Sergio Laranjo from the Hospital Santa Marta in Lisbon, Portugal. Although majority of the participants could return to work, their fear of fainting triggered their inactivity, which is typical for individuals with recurrent fainting episodes, he added. “For some … it is life-limiting – they end up in emergency or admitted to hospital, and fear stops them from working and socializing.”

“None of the conventional treatments had helped, but after tilt training they stopped fainting and were able to resume their jobs,” said Laranjo. Tilt training enabled participants to lead ‘full, normal lives’, he added, given the QoL improvements relative to worry, fear, and frustration about future fainting episodes (p<0.05).

“[Overall,] these results are associated with a significant modulation of ANS function, leading to a more homeostatic response and a better baroreflex function,” said Laranjo. “Tilt training may be an effective therapeutic option with long-term benefits and a significant impact in QoL [for individuals with refractory RS].”

While the results underscore the potential of tilt training in this setting, given the lack of effective treatment, ESC* guidelines recommend referral to a one-stop multidisciplinary syncope unit for assessment, diagnosis, therapy, and follow-up. [Eur Heart J 2018;39:1883-1948]