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Orthostatic Syncope

Syncope Due to Orthostatic Hypotension

Orthostatic syncope is a term describing the loss of consciousness in association with orthostatic hypotension. After suddenly standing up and a sudden drop in blood pressure, patients report fainting episodes and lightheadedness. A detailed patient history and a physical examination, during which serial blood pressure measurements are made, are mandatory components of the diagnostic workup.


Presentation

When the patient changes from supine to standing position, about 10-15% of all blood pools in the venous system of the lower extremities [1] [2]. The sudden action of standing up might lead to an abnormal vasomotor response by causing sharp decreases in blood pressure and could result in hypoperfusion of tissues (particularly of the central nervous system) [1] [2]. This phenomenon is known as initial orthostatic hypotension, characterized by a transient fall of systolic and diastolic pressures of > 40 mmHg and/or > 20 mmHg, respectively [3] [4] [5]. The inadequate perfusion of tissues seen when initial orthostatic hypotension ensues principally manifests as a transient loss of consciousness (syncope), which may be preceded by dizziness (pre-syncope) [1] [2]. Orthostatic syncope develops approximately 5-10 seconds after suddenly standing up [4]. Additional symptoms that have been described in the literature are lightheadedness, headaches, visual disturbances, dyspnea, muscle weakness, a transient cognitive decline, and shoulder discomfort [6] [7]. This form of syncope is especially prevalent among the elderly, in whom baroreceptor activity and the mechanisms involved in blood pressure regulation are not optimally efficient [1].

Hemophilia A
  • Stay up to date with new chapters on Clotting Disorders and Hemophilia, Patient-Centered Care, Health Disparities and Diversity in Emergency Medicine, Cost-Effectiveness Analysis, Antibiotic Recommendations for Empirical Treatment of Selected Infectious[books.google.com]
Anemia
  • […] loop diuretics (furosemide, bumetanide) Dehydration (low fluid volume in the body) Immobility (for instance, staying in bed for a long time) Pregnancy Heart conditions, including heart attack, heart failure, irregular heart rhythm, and valve disease Anemia[my.clevelandclinic.org]
  • These may include a red blood cell count ( CBC ) to access for anemia or bleeding.[rxlist.com]
  • The heart pumps blood, and if there is too little blood volume (anemia, dehydration, dialysis), the pressure drops.[dizziness-and-balance.com]
  • Historical Clues to Diagnosis of Orthostatic Hypotension Historical features Possible etiology Abnormal uterine bleeding, fatigue, rectal bleeding Anemia Amaurosis fugax, aphasia, dysarthria, unilateral sensory and motor symptoms Stroke Bradykinesia,[aafp.org]
Malingering
  • Psychiatric disorders that may have a LOC include conversion disorders, malingering, and Munchausen's syndrome. 68 Characteristics of "hysterical syncope" include secondary gain, occurrence before an audience, attention-seeking behavior, lack of injuries[ahcmedia.com]
Chest Discomfort
  • Typical symptoms of complaints from POTS patients may include headache, poor concentration, dizziness, fatigue, tremor, chest discomfort, and shortness of breath.[frontiersin.org]
Dysphagia
  • Several studies have reported the clinical symptoms associated with CM-I, including suboccipital headache, weakness in the upper extremities, facial numbness, loss of temperature sensation, ataxia, diplopia, dysarthria, dysphagia, vomiting, vertigo, nystagmus[kjp.or.kr]
  • Dysphagia 2005; 20:273–277. Benditt DG, Samniah N, Pham S, et al. Effect of cough on heart rate and blood pressure in patients with “cough syncope.” Heart Rhythm 2005; 2:807–813. Mimura T, Funatsu H, Yamagami S, et al.[clevelandclinicmeded.com]
Facial Numbness
  • Several studies have reported the clinical symptoms associated with CM-I, including suboccipital headache, weakness in the upper extremities, facial numbness, loss of temperature sensation, ataxia, diplopia, dysarthria, dysphagia, vomiting, vertigo, nystagmus[kjp.or.kr]
Nocturnal Polyuria
  • Use with care tds with last dose early evening Specific targeting: Octreotide – for post-prandial hypotension Desmopressin – with Fludrocortisone if nocturnal polyuria Erythropoietin – for refractory anaemia in renal failure Back to Syncope .[syncope.co.uk]
Dizziness
  • The inadequate perfusion of tissues seen when initial orthostatic hypotension ensues principally manifests as a transient loss of consciousness (syncope), which may be preceded by dizziness (pre-syncope).[symptoma.com]
  • Additional mental loading could be a useful countermeasure to alleviate the orthostatic responses of persons, particularly in those with histories of dizziness on standing up, or to alleviate hypotension that frequently occurs during hemodialysis or on[ncbi.nlm.nih.gov]
  • Usually the patient will complain of blackouts and dizzy turns, the result of impaired cerebral perfusion. Links: aetiology diagnosis and investigation management syncope[gpnotebook.co.uk]
  • The recurrence of syncope was not related to the degree of orthostatic hypotension; however, the recurrence of dizziness and syncope as end-points was lower in patients with 20 mm Hg or greater systolic blood pressure reductions as compared with patients[ncbi.nlm.nih.gov]
  • It can produce dizziness and fainting.[medical-dictionary.thefreedictionary.com]
Nystagmus
  • Several studies have reported the clinical symptoms associated with CM-I, including suboccipital headache, weakness in the upper extremities, facial numbness, loss of temperature sensation, ataxia, diplopia, dysarthria, dysphagia, vomiting, vertigo, nystagmus[kjp.or.kr]

Workup

The diagnosis of orthostatic syncope rests on the ability of the physician to obtain a detailed patient history and conduct a meticulous physical examination. In fact, the role of a proper patient interview has shown to be pivotal in establishing the underlying cause of syncope [8]. However, the diagnosis of orthostatic syncope can be confirmed by series of blood pressure measurements or continuous blood pressure monitoring [2] [3] [5]. Some authors recommend that blood pressure should be measured after 5 minutes of lying followed by few measurements after standing up (for 3-5 minutes). Physicians should note whether dizziness and light-headedness appear [2] [3]. In rare cases, patients may not be able to stay in standing position throughout the entire examination [2], which is an important clue for the diagnosis of orthostatic syncope. The possibility of constant blood pressure measurement during this period significantly increases the chance of confirming the diagnosis [2] [3] [4]. Additionally, the head-up tilt test is described in the literature as a possible method to assess orthostatic hypotension [2]. Furthermore, a complete cardiac exam, comprised of electrocardiography (ECG) and cardiac ultrasonography is recommended [4]. The differential diagnosis of orthostatic syncope is quite broad, indicating that a more detailed evaluation (particularly of the central nervous system) might be necessary [6].

Suppression

Treatment

  • Get clear, concise descriptions and evidence-based treatment guidelines for a full range of clinical conditions, ranging from the common to the unusual.[books.google.com]
  • • judicious exercise • counter physical manoeuvres Consider: • Compression stockings • abdominal binders • anti-gravity suit if very symptomatic and all else fails • oral water ingestion – 400 mls significantly increases BP in autonomic failure Drug treatment[syncope.co.uk]
  • Hospitalisations for syncope were predicted by higher SBP, antihypertensive treatment, in particular use of diuretics, and baseline CV disease, whereas OH-related hospital admissions were predicted by history of diabetes, but not by antihypertensive treatment[heart.bmj.com]
  • We included randomized controlled trials of patients with SOH or RRS that compared treatment with midodrine against a control and reported data on patient important outcomes.[neurology.org]
  • Treatment Put the patient flat onto her left side or in a sitting position.[med-college.de]

Prognosis

  • . ; Gallina, Sabina ; De Caterina, Raffaele ; Fedorowski, Artur doi: 10.1097/HJH.0000000000001215 ORIGINAL PAPERS: Elderly Abstract In Brief Author Information Authors Article Metrics Metrics We explored incidence, predictors, and long-term prognosis[journals.lww.com]
  • Prognosis is poor with a median survival of 6-9 years. The documents contained in this web site are presented for information purposes only.[orpha.net]
  • […] method in-office (lay down for at least 20 minutes, take BP; stand for 3 minutes, take BP), or tilt-table testing by an autonomic specialist Treatment identify and treat causes (medications, dehydration), midodrine, compression garments, bed tilting Prognosis[en.wikipedia.org]
  • Prognosis The prognosis for people who have orthostatic hypotension depends on the underlying cause of the problem. Prevention There is no way to prevent orthostatic hypotension, since it is usually the result of another medical condition.[medical-dictionary.thefreedictionary.com]
  • Incidence and prognosis of syncope. N Engl J Med. 2002;34(12)7:878–85.[escardio.org]

Etiology

  • Etiologic and clinical implications. Am J Med, 1983; 74: 265–271.[journals.viamedica.pl]
  • Etiology Overview of possible causes of syncopes Pathophysiology Subtype Etiology Examples Cardiac syncope Heart 's inability to meet an increased oxygen demand (e.g., during exertion) reduced cerebral perfusion Arrhythmogenic syncope Bradycardia / tachycardia[amboss.com]
  • Etiology Etiology of MSA is unknown but presence of cytoplasmic aggregates of α-synuclein, primarily in oligodendroglia, in combination with neurodegeneration in striatonigral and olivopontocerebellar structures are the pathological hallmark features.[orpha.net]
  • Most etiologies of syncope are benign, although some causes are life-threatening and syncope can be the harbinger of sudden death.[ahcmedia.com]

Epidemiology

  • Summary Epidemiology Prevalence ranges from 1/50,000-1/20,000. MSA-parkinsonian type (MSA-p) predominates in the Western Hemisphere and MSA-cerebellar type (MSA-c) predominates in the Eastern Hemisphere. Genders are equally distributed.[orpha.net]
  • Methods Statistics Trigonometry Medical & Nursing Anatomy Anesthesiology Audiology Bacteriology Biochemistry Bioethics Biomedical Science Cardiology Cardiovascular Childbirth Chiropractic Dentistry Dermatology Diagnostic Imaging Drugs Endocrinology Epidemiology[brainscape.com]
  • Epidemiology and prognostic implications of syncope in young competing athletes. Eur Heart J 2004;25:1749-53.[acc.org]
  • Epidemiology of reflex syncope. Clin. Auton. Res. 1, 9–17. doi: 10.1007/s10286-004-1003-3 Pubmed Abstract Pubmed Full Text CrossRef Full Text Convertino, V. A. (2001).[frontiersin.org]
  • […] have reflex syncope are usually evaluated as outpatients without hospitalisation. 14 Strengths and weaknesses in relation to other studies The average rate of hospital admissions for syncope was 1.2 per 1000 person-years, which is consistent with the epidemiological[heart.bmj.com]
Sex distribution
Age distribution

Pathophysiology

  • In this regard, many neuropeptides (NPs) or peptide hormones (PH) exert cardio-active effects that might contribute to the pathophysiology of certain forms of syncope or OI.[journals.viamedica.pl]
  • Neural reflex regulation of arterial pressure in pathophysiological conditions: interplay among the baroreflex, the cardiopulmonary reflexes and the chemoreflex. Braz. J. Med. Biol.[frontiersin.org]
  • Autonomic Disorders, 681-697, 1997 被引用文献1件 23 Postural tachycardia syndrome LOW PA Clinical Autonomic Disorders, 515-533, 2008 被引用文献1件 25 Cardiopulmonary receptor reflex in hypertension MANCIA G Am J Hypertens 1, 249-255, 1988 被引用文献1件 31 The elusive pathophysiology[ci.nii.ac.jp]
  • The classification of syncope is based on the underlying pathophysiological mechanism causing the event, and includes cardiac, orthostatic and reflex (neurally mediated) mechanisms.[samj.org.za]
  • Etiology Overview of possible causes of syncopes Pathophysiology Subtype Etiology Examples Cardiac syncope Heart 's inability to meet an increased oxygen demand (e.g., during exertion) reduced cerebral perfusion Arrhythmogenic syncope Bradycardia / tachycardia[amboss.com]

Prevention

  • 08; :1-13 Jensen JL, Ohshimo S, … First Aid and Pediatric Task Forces of the International Liaison Committee on Resuscitation CONCLUSIONS: While there is a minimal amount of evidence available and the findings were mixed, PCM may provide benefit for prevention[unboundmedicine.com]
  • Beta blocker medications such as metoprolol (Inderal) block the beta-adrenergic receptors in the body, preventing the heart from speeding up, preventing the heart from contracting as forcefully, and dilating blood vessels.[rxlist.com]
  • Various maneuvers can also be performed to prevent dizziness from progressing to syncope.[andorrapediatrics.com]
  • How can I prevent the symptoms occurring? Take particular care in the morning. Blood pressure tends to be lowest in the morning and your symptoms are likely to be worst then. Get out of bed in stages.[newcastle-hospitals.org.uk]
  • Beta blocker medications such as metoprolol ( Inderal ) block the beta-adrenergic receptors in the body, preventing the heart from speeding up, preventing the heart from contracting as forcefully, and dilating blood vessels.[medicinenet.com]

References

Article

  1. Arthur W, Kaye GC. The pathophysiology of common causes of syncope. Postgrad Med J. 2000;76:750–753.
  2. Naschitz JE, Rosner I. Orthostatic hypotension: framework of the syndrome. Postgraduate Medical Journal. 2007;83(983):568-574.
  3. Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ, Bloch Thomsen PE. European Society of Cardiology. Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J. 2001;22:1256–1306.
  4. Vaddadi G, Lambert E, Corcoran SJ, Esler MD. Postural syncope: mechanisms and management. Med J Aust. 2007;187(5):299-304.
  5. Wieling W, Krediet CT, van Dijk N, Linzer M, Tschakovsky ME. Initial orthostatic hypotension: review of a forgotten condition. Clin Sci (Lond). 2007;112(3):157-165.
  6. Low PA, Tomalia VA. Orthostatic Hypotension: Mechanisms, Causes, Management. J Clin Neurol. 2015;11(3):220-226.
  7. Nwazue VC, Raj SR. Confounders of Vasovagal Syncope: Orthostatic Hypotension. Cardiol Clin. 2013;31(1):89-100.
  8. Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001;37(7):1921-1928.

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Last updated: 2017-08-09 14:57