The tilt table test can be performed by a trained nurse or medical doctor or both of them according to the local law. The providers should be certified and able to give basic life support (BLS) if needed.

The patient should fast for at least 4 hours to avoid aspiration during vomiting in an unconscious state (which is rare). The examination may be performed when the patient is dressed in their usual clothes. The procedure and expectations should be explained to avoid unnecessary anxiety about the test. The patient should be informed about the risk of urinary incontinence or vomiting and have clothes to change into, if necessary.

Before tilt table testing, the patient should stay in the supine position for at least 5 minutes. A long time in the supine position is required if venous catheterization is to be done before the test. The patient should be wrapped to avoid falls and traumatic injuries. Venous catheterization is not mandatory before tilt testing.

Blood pressure and ECG should be monitored. The best method to monitor blood pressure is to use continuous non-invasive blood pressure monitoring, but using a sphygmomanometer is allowed.

The tilt table test should be performed according to the chosen protocol. There are a few protocols that can be used. The best-known in medical practice are the Westminster protocol or the Italian protocol. During the tilt table test, the passive phase is recommended to last 20 to 45 minutes. Later, medication is given (most commonly 0.4 mg nitroglycerine sublingually) to increase the sensitivity of the test, but the provocation reduces the specificity, and the patient should be in an upright position for up to 15 minutes.

The tilt table test should be terminated at syncope or after protocol termination. Some patients have prolonged hypotension without loss of consciousness, and in this case, the termination of tilt testing during the pre-syncopal period may be considered, especially in elderly patients.In the case of a positive result during the tilt table test, the patient should be asked about reproducing symptoms in his or her daily life. The downtime should be shorter than 10 seconds. Lowering the tilt table for a longer period may result in a longer loss of consciousness. The changes in blood pressure and heart rate should be assessed.

The tilt table test is a safe procedure. However, myocardial infarction or stroke may develop in persons with significant coronary or carotid artery stenosis. This is very rare. Arrhythmic complications may be represented by prolonged bradycardia, which may be treated with atropine. Ventricular fibrillation is extremely rare. Some patients may vomit after tilt testing or have severe weakness lasting for several hours. A headache is common, especially after nitroglycerine use. A few seconds of extremity myoclonus is common after syncope noted before returning to consciousness (convulsive syncope). This should not be confused by the providers for seizures.[11]

The cardioinhibitory component of neurocardiogenic reflex provoked during tilt testing is a significant concern for attending doctors because the decision to pace or not to pace needs to be considered. The proper management of patients with a cardioinhibitory form of neurocardiogenic reflex is still a matter of debate. Cases of pacemaker implantation in young people with a single syncopal event were reported during cardiology conferences. They were justified by the doctors who worry about the risk of cardiac arrest. However, this approach may lead to infectious complications, need for future reimplantation procedures, reduced quality of life, anxiety, and depression. The cardioinhibitory component may be related both to inhibition of sinus node presenting as sinus bradycardia or sinus standstill or inhibition of an atrioventricular node presenting as an atrioventricular block. The patients with an atrioventricular block during neurocardiogenic reflex provoked by tilt table tests have shorter prodromal symptom duration. They tend to have a longer PR interval on an electrocardiogram at baseline. At present, the appropriateness of pacing the patients with tilt table test induced asystole should be assessed in a clinical context. Elderly patients may be considered to be paced because of the risk of overlapping sick sinus syndrome or concealed dysfunction of the atrioventricular node. Pacing in patients at an age younger than 40 years is usually not indicated.

Clinicians should be aware that the tilt table it not 100% sensitive in making a diagnosis of syncope; other methods of evaluating the patient should also be undertaken.

The VASIS classification may be used when a neurocardiogenic reflex is provoked. In this case, mixed reaction, cardioinhibitory (asystole at least 3 seconds or bradycardia lower than 40/min lasting at least 10 seconds), and a vaso-depressive form may be recognized. However, other forms of hemodynamic instability may be present, including initial orthostatic hypotension, delayed orthostatic hypotension, or postural orthostatic tachycardia (increase in heart rate greater than 30/min or above 130/min). The neurocardiogenic reflex may be provoked by orthostatic hypotension or delayed orthostatic hypotension.[12][13][14][15]