PROCEDURE PERFORMED: Tilt table test.
INDICATION AND HISTORY: This is a (XX)-year-old male with history of craniopharyngioma status post surgery and hypertension, who has been having episodes of lightheadedness and near syncope after surgery. The patient was referred for further evaluation of autonomic function.
DESCRIPTION OF PROCEDURE: The risks, benefits, and alternatives of procedure were explained to patient. All his questions were answered, and he understood and signed informed consent.
The patient was brought to the electrophysiology lab in a fasting, nonsedated state. He was tilted to 70 degrees under continuous blood pressure, heart rate, EKG, and pulse oximeter monitoring. Baseline blood pressure was 122/74 and heart rate was 64.
Immediately after tilt, the blood pressure was 126/94 and heart rate was 88.
During the next five minutes, the blood pressure remained stable at 126/86 and heart rate was 77. Sublingual nitroglycerin was given at this point, immediately after which the blood pressure was 128/87, heart rate was 76.
During the next three minutes, the blood pressure was relatively stable at around 118/96 and heart rate increased to a maximum of 98 beats per minute. During this time, the patient started feeling lightheaded, pale, and nauseated and then passed out, and the blood pressure could not be measured, and he was returned to the supine position immediately. At this point, his heart rate was about 74 beats per minute.
Immediately after returning, the blood pressure was 86/57 and heart rate was 70. The patient tolerated the procedure well, and there were no complications.
CONCLUSION: Positive tilt table test with vasodepressor response.
PLAN: The patient will be observed for a short period and can be discharged home afterwards. The etiology of his lightheaded and presyncopal spells is most likely vasovagal with a large vasodepressor component.
Our recommendation would be to increase fluid intake. Also, we have recommended stopping his antihypertensive gradually over two or three days and then reassess his blood pressure, and if he requires any antihypertensive medication, a beta blocker may be a more suitable option at this point. He should definitely avoid taking any diuretics or vasodilators.
Also, we have prescribed supportive stockings. Also, of concern is that the patient is being replaced with Synthroid and dexamethasone. We are not sure if he requires Florinef also as a part of replacement therapy after his pituitary surgery. This should be evaluated by his endocrinologist.
