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].

• Anemia

  Biaggioni et al. found that the serum erythropoietin level was lower in patients with anemia due to autonomic failure than in patients with iron-deficiency anemia (unpublished data). [nejm.org]

  […] 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]

• Hypoxemia

  100mg and ergotamine 100mg Differential Diagnosis Differential diagnosis includes other causes of loss of consciousness Seizures Hypoglycemia Concussion secondary to head trauma Drug or alcohol intoxication Metabolic conditions including hypothyroidism, hypoxemia [ncbi.nlm.nih.gov]

• 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]

• Hyperpnea

  In this article, mechanisms for OI having components of adrenergic hypofunction, adrenergic hyperfunction, hyperpnea, and regional blood volume redistribution are discussed. [pediatrics.aappublications.org]

• Heart Block

  Acquired causes of atrioventricular heart block are probably more common than congenital heart block. The most common etiology of acquired heart block is a postoperative complication of cardiac surgery. [ahcmedia.com]

  In one study following 95 syncope patients, the majority of abnormalities found on 24-hour Holter recordings included bradycardia 2 seconds, Mobitz II conduction block, complete heart block, ventricular tachycardia, and premature ventricular contractions [ceemjournal.org]

  Cardiac pump failure refers to when the heart cannot pump blood sufficiently enough to maintain blood flow to meet the demands of the body and can be associated with heart block, disorders of heart rhythm (tachyarrhythmias), narrowing (stenosis) of the [rarediseases.org]

  The American Heart Association/American College of Cardiology/Heart Rhythm Society pacemaker practice guidelines provide further details (34). Figure 2. Paroxysmal AV block resulting in transient bradycardia in an older woman with recurrent syncope. [scielo.edu.uy]

• Exercise-Induced Syncope

  Red flags for potential cardiac aetiology are: lack of prodrome palpitations or chest pain exercise-induced syncope past cardiac history family history of early cardiac death, arrhythmia or sudden death. [rch.org.au]

  Unlikely in younger patients in the absence of cardiac history; exercise induced syncope; may be associated with cardiac signs or abnormal ECG. Cardiac outflow obstruction Symptoms on exercise; rapid recovery usual. [rcemlearning.co.uk]

  Stress testing Exercise induced syncope is infrequent but exercise testing should be performed in patients who experience syncope during or shortly after exertion.2 Stress testing should be avoided in patients with severe, symptomatic aortic stenosis [clevelandclinicmeded.com]

• Arthritis

  NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases [medlineplus.gov]

  The time of onset can vary from patient to patient based on the volume status, baseline activities, family support, and co-morbid conditions such as hypertension, diabetes, arthritis, and dementia. [tandfonline.com]

  Strangely, in this study, arthritis of the hip with no clear causative mechanism was found in several family members with OI type V and a sporadic case. We hypothesized that this arthritis may be caused by the same pathogenic mechanism. [frontiersin.org]

  The impairment due to syncope is comparable with chronic illnesses such as chronic arthritis, recurrent moderate depressive disorders and end-stage kidney disease. [patient.info]

  Alto, CA 94303 Phone: (650) 462-3174 Email: [email protected] Website: http://www.letthemhear.org March of Dimes 1550 Crystal Dr, Suite 1300 Arlington, VA 22202 USA Phone: (888) 663-4637 Website: http://www.marchofdimes.org NIH/National Institute of Arthritis [rarediseases.org]

• Prolapse

  […] ejection fraction Sick sinus syndrome Ventricular tachycardia Atrioventricular block Supraventricular arrhythmias Adams-Stokes syndrome Torsades de pointes Cardiovascular syncope Structural outflow obstruction Massive MI Aortic stenosis Mitral valve prolapse [amboss.com]

  Cardiac effects are important; they include aortic incompetence, aortic root widening and mitral valve prolapse. Often there is hypermobility of joints, with flat feet, hyper-extensible large joints and dislocations. [patient.info]

  Philip Low. 8 However, POTS is not a new illness; it has been known by other names throughout history, such as DaCosta's Syndrome, Soldier's Heart, Mitral Valve Prolapse Syndrome, Neurocirculatory Asthenia, Chronic Orthostatic Intolerance, Orthostatic [dysautonomiainternational.org]

  Patients with noncorrected congenital heart disease who are especially vulnerable to sudden death include patients with Eisenmenger's syndrome, Ebstein anomaly, atrioventricular canal, aortic stenosis, coronary artery abnormalities, and mitral valve prolapse [ahcmedia.com]

• 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]

  All the general information concerning the mechanisms causing unconsciousness, the symptoms and the different types of syncope are presented under the heading: The syncope, a dizzying subject. [icardio.ca]

  Symptoms generally include DIZZINESS, blurred vision, and SYNCOPE. [fpnotebook.com]

  Usually the patient will complain of blackouts and dizzy turns, the result of impaired cerebral perfusion. Links: aetiology diagnosis and investigation management syncope [gpnotebook.com]

  Orthostatic hypotension signs and symptoms include: Feeling lightheaded or dizzy after standing up Blurry vision Weakness Fainting (syncope) Confusion Nausea When to see a doctor Occasional dizziness or lightheadedness may be fairly minor — triggered [mayoclinic.org]

• Aura

  Results: Migraine without aura was diagnosed in 36 and with aura in 47 patients. Syncope occurred during a passive tilting in 2,3% of patients with migraine without aura (other 2,3% reported presyncopal symptoms), and in 6,1% of controls. [child-neurology.eu]

  References:[2][3][5][9][10][11] Differential diagnoses Non-syncopal events Medical history and clinical features Diagnosis Seizure Epileptic symptoms (e.g., aura, postictal state, lateral tongue biting, bladder/bowel incontinence) Abnormal EEG Brain lesions [amboss.com]

  1) A classic aura or postictal confusion and muscle pain indicate seizure 2) A prolonged postictal phase is more consistent with seizure 2) Prodromal symptoms of nausea and diaphoresis suggest reflex-mediated (vasovagal) syncope Umm what random exam must [quizlet.com]

  With syncope, there is no aura and the LOC is very brief, with rapid recovery to normal alertness/mental status within seconds without any postictal confusion, sleepiness, or headache. [ahcmedia.com]

  Table 2: Differential diagnosis of non-syncopal transient loss of consciousness Disease Clinical Features Epileptic seizure May be preceded by aura. Post ictal state common. Unlikely if recovery is rapid. [rcemlearning.co.uk]

• Excitement

  Discussion Baroreceptors are mechanoreceptor sensory neurons that are excited by stretching of the corresponding blood vessel. [tandfonline.com]

  The European Society of Cardiology identifies potential ECG abnormalities that can lead to cardiac syncope, such as prolonged intervals (QRS interval, QTc), severe bradycardia, and evidence of pre-excitation (Wolff-Parkinson-White) [ 22 ]. [ceemjournal.org]

• Somnolence

  The presence of any of the following are consistent with a seizure not syncope: focal neurologic signs (by history or examination), an aura preceding the LOC, post-episode confusion/somnolence/headache, incontinence of bladder and/or bowel, tongue-biting [ahcmedia.com]

• Hyperreflexia

  In some cases, pyramidal signs (generalized hyperreflexia and positive Babinski sign) are observed. [orpha.net]

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].

• Hypocapnia

  Therapeutic strategies to cope with OI are proposed. syncope postural tachycardia syndrome orthostatic hypotension autonomic nervous system hypocapnia Abbreviations: ANS — autonomic nervous system BP — blood pressure CBF — cerebral blood flow CBFv — cerebral [pediatrics.aappublications.org]

  Hyperventilation syncope is due to cerebral arterial vasoconstriction secondary to hypocapnia from the hyperventilation. [ahcmedia.com]

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]

In selected patients with suspected neurodegenerative disease and syncope, referral for autonomic evaluation is reasonable to improve diagnostic and prognostic accuracy.[5] Treatment / Management Treatment of orthostatic syncope depends on the underlying [ncbi.nlm.nih.gov]

Naturally some syncopal events will lead to diagnosis of severe underlying cardiac disease resulting in adverse prognosis, but for the majority, it is considered a benign event without need for any further scrutiny. [heart.bmj.com]

Prognosis for orthostatic syncope depends on the underlying cause of orthostatic hypotension. [ncbi.nlm.nih.gov]

Syncope Summary Etiology Clinical features Diagnostics Differential diagnoses Treatment Complications [amboss.com]

Effective treatment depends on determining the underlying etiology and instituting appropriate interventions to reduce the risk of harm to the patient. [ncbi.nlm.nih.gov]

All aspects of VVS are covered, including epidemiology, pathophysiology, diagnosis and differential diagnosis, prognosis, therapy and implications for particular activities such as work, driving and physical activity. [books.google.com]

[…] general population Martin H Ruwald Correspondence to Dr Martin H Ruwald, Department of Cardiology, Herlev-Gentofte Hospital, Hellerup 2900, Denmark; mruwald{at}hotmail.com Statistics from Altmetric.com electrophysiology quality and outcomes of care epidemiology [heart.bmj.com]

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]

Non-neurally mediated causes include: Medications (antihypertensives, vasodilators) Decreased blood volume (adrenal insufficiency, blood loss, dehydration, hypovolemia or decreased effective intravascular volume) Physical deconditioning Sympathectomy Epidemiology [ncbi.nlm.nih.gov]

While many pathophysiological aspects of VVS have been clarified, others remain elusive. The diagnosis of VVS may be easy, but it is sometimes challenging. [books.google.com]

According to pathophysiologic mechanisms the syncope can be divided into a reflex, orthostatic syncope due to arrhythmia or structural heart disease, cerebrovascular diseases and a psychogenic and neurological causes. [worldcat.org]

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]

Pathophysiology Onychia results from the introduction of microscopic pathogens through small wounds. Causes Common Causes Onychia can be caused by manicuring instruments that have not been properly disinfected. [wikidoc.org]

Preventing Broken Bones Preventing bone fractures is key for people with OI. [kidshealth.org]

Much less frequent and clinically much more grave is orthostatic hypotension due to sympathetic-nervous-system failure, in which the fundamental disturbance is a failure of reflex adrenergic cardiovascular activity to prevent hypotension from the normal [nejm.org]

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]

Usefulness of orthostatic self-training for the prevention of neurocardiogenic syncope. [ahajournals.org]

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.