Autonomic Testing Guidelines

Appropriate Clinical Settings and Patient Preparation

The European Society of Cardiology recommends that autonomic testing should be performed in a dedicated laboratory with specialized equipment, including beat-to-beat blood pressure monitoring, ECG monitoring, and a motorized tilt table, in a quiet environment with temperature controlled between 21-23°C, and patients should fast for 3 hours before testing and avoid nicotine, caffeine, theine, or taurine-containing drinks on the day of examination 1
Patients should be referred to specialized autonomic function laboratories in cardiology or neurology departments where testing can be performed by specialists trained in autonomic function testing and interpretation 1

The American Heart Association recommends autonomic testing for patients with known or suspected neurodegenerative disease, where autonomic evaluation can improve diagnostic and prognostic accuracy, as well as for patients with Parkinsonism, peripheral neuropathies, or diseases associated with peripheral neuropathy 2, 3
Autonomic testing is also recommended for patients with progressive autonomic dysfunction, postprandial hypotension, and neuropathic postural tachycardia syndrome (POTS) 2, 3
The American Gastroenterological Association recommends referral to specialty practices for POTS testing in patients with symptomatic increase in heart rate of 30 beats/min or more with 10 minutes of standing, and for patients with hypermobile Ehlers-Danlos syndrome (hEDS) who have refractory GI symptoms and orthostatic intolerance 4

The American Academy of Physical Medicine and Rehabilitation recommends cardiovagal function tests, including heart rate variability to deep breathing and Valsalva maneuver response, as part of comprehensive autonomic testing 5, 6, 7

The European Society of Cardiology notes that no single autonomic function test can provide a comprehensive assessment of the autonomic nervous system, and different clinical questions require different batteries of tests 1
The American Heart Association recommends that autonomic testing should be performed by specialists who understand the pathophysiology of the autonomic nervous system and the pharmacology of treatments for neurodegenerative disease 2, 3
The American Gastroenterological Association recommends referral to an allergy specialist or mast cell disease research center for patients with suspected mast cell activation syndrome (MCAS) for additional specialized testing 4

The European Association for the Study of Diabetes recommends avoiding testing during acute illness, stressful conditions, fever, infection, or dehydration, and testing should not be performed during hypoglycemia or marked hyperglycemia 8
Tests should be performed at least 2 hours after short-acting insulin administration, and consider appropriate wash-out of interfering drugs, particularly diuretics, sympatholytic agents, and psychoactive drugs 8
Test results should be interpreted with caution in the presence of respiratory or cardiovascular diseases, particularly heart failure, and age-related normal reference values are required to correctly interpret the results of heart rate-based cardiovascular tests 8