Orthostatic syncope refers to syncope resulting from a postural decrease in blood pressure, termed

orthostatic hypotension Orthostatic hypotension, also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when standing up or sitting down. Primary orthostatic hypertension is also often referred to as neurogenic orthostatic hyp ...

. Orthostatic hypotension occurs when there is a persistent reduction in

blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...

of at least 20mmHg systolic or 10mmHg diastolic within 3 minutes of standing or being upright to 60 degrees on the head-up

tilt table A tilt table test (TTT), occasionally called upright tilt testing (UTT), is a medical procedure often used to diagnose dysautonomia or syncope. Patients with symptoms of dizziness or lightheadedness, with or without a loss of consciousness ( f ...

. In people with initial orthostatic hypotension, the decrease in blood pressure occurs within 15 seconds, while in those with ''delayed'' orthostatic hypotension it occurs after over 3 minutes of assuming an upright position.

Signs and symptoms

Orthostatic syncope may occur suddenly with no warning or may be preceded by symptoms. Associated symptoms are usually because of cerebral hypoperfusion occurring in the upright position and include

dizziness Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness. Dizziness is a common medical c ...

, feeling faint or nauseated,

diaphoresis Perspiration, also known as sweating, is the production of fluids secreted by the sweat glands in the skin of mammals. Two types of sweat glands can be found in humans: eccrine glands and apocrine glands. The eccrine sweat glands are distribut ...

, a sense of warmth or

blurred vision Blurred vision is an ocular symptom where vision becomes less precise and there is added difficulty to resolve fine details. Temporary blurred vision may involve dry eyes, eye infections, alcohol poisoning, hypoglycemia, or low blood pressure. ...

. Other general symptoms regardless of the position include a feeling of generalized weakness,

headache Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a result ...

fatigue Fatigue describes a state of tiredness that does not resolve with rest or sleep. In general usage, fatigue is synonymous with extreme tiredness or exhaustion that normally follows prolonged physical or mental activity. When it does not resolve ...

, cognitive slowing and

shortness of breath Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...

. Symptoms may be sudden or gradual, getting progressively worse until the patient loses consciousness. Patients may have a single episode with an identifiable precipitating factor or recurrent episodes without an overt, identifiable, precipitating factor. Blood pressure and

heart rate Heart rate (or pulse rate) is the frequency of the heartbeat measured by the number of contractions (beats) of the heart per minute (bpm). The heart rate can vary according to the body's physical needs, including the need to absorb oxygen and excr ...

should be measured in

supine In grammar, a supine is a form of verbal noun used in some languages. The term is most often used for Latin, where it is one of the four principal parts of a verb. The word refers to a position of lying on one's back (as opposed to 'prone', lyi ...

and

standing position Anatomical terminology is a form of scientific terminology used by anatomists, zoologists, and health professionals such as doctors. Anatomical terminology uses many unique terms, suffixes, and prefixes deriving from Ancient Greek and Latin. The ...

s. As described above, orthostatic hypotension diagnosis is when there is a drop of greater than or equal to 20 mmHg or greater or equal to 10 mmHg in systolic and diastolic blood pressures, respectively within 3 minutes of standing. In the case of

hypovolemia Hypovolemia, also known as volume depletion or volume contraction, is a state of abnormally low extracellular fluid in the body. This may be due to either a loss of both salt and water or a decrease in blood volume. Hypovolemia refers to the los ...

, there is also a compensatory rise in heart rate of greater than 15 beats/minute.

Complications

Complications of orthostatic syncope include: #

Trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...

injury An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, o ...

from falls during an episode of orthostatic syncope. #

Stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...

from changes in blood pressure due to decrease blood flow to the brain. #

Cardiovascular The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...

complications including

heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...

chest pain Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...

, and

arrhythmia Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults ...

Etiology

There are multiple causes of orthostatic hypotension which could lead to syncope including neurally mediated (

neurogenic In Biology, biology, the nervous system is the Complex system, highly complex part of an animal that coordinates its Behavior, actions and Sense, sensory information by transmitting action potential, signals to and from different parts of its ...

) and non-neurally mediated causes. Neurally mediated causes include conditions that cause either primary or secondary failure of the autonomic system: *

Peripheral neuropathy Peripheral neuropathy, often shortened to neuropathy, is a general term describing disease affecting the peripheral nerves, meaning nerves beyond the brain and spinal cord. Damage to peripheral nerves may impair sensation, movement, gland, or or ...

as seen in

diabetes mellitus Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...

alcoholics Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomina ...

nutritional Nutrition is the biochemical and physiological process by which an organism uses food to support its life. It provides organisms with nutrients, which can be metabolized to create energy and chemical structures. Failure to obtain sufficient nu ...

(

vitamin B12 deficiency Vitamin B12 deficiency, also known as cobalamin deficiency, is the medical condition in which the blood and tissue have a lower than normal level of vitamin B12. Symptoms can vary from none to severe. Mild deficiency may have few or absent symp ...

amyloidosis Amyloidosis is a group of diseases in which abnormal proteins, known as amyloid fibrils, build up in tissue. There are several non-specific and vague signs and symptoms associated with amyloidosis. These include fatigue, peripheral edema, weight ...

*Idiopathic

postural hypotension Orthostatic hypotension, also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when standing up or sitting down. Primary orthostatic hypertension is also often referred to as neurogenic orthostatic hyp ...

* Multi-system atrophies (

parkinsonism Parkinsonism is a clinical syndrome characterized by tremor, bradykinesia (slowed movements), rigidity, and postural instability. These are the four motor symptoms found in Parkinson's disease (PD), after which it is named, dementia with Lewy bo ...

, progressive cerebellar degeneration,

dementia with Lewy bodies Dementia with Lewy bodies (DLB) is a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions. Memory loss is not always an early symptom. The disease worsens over time ...

) *Acute

dysautonomia Dysautonomia or autonomic dysfunction is a condition in which the autonomic nervous system (ANS) does not work properly. This may affect the functioning of the heart, bladder, intestines, sweat glands, pupils, and blood vessels. Dysautonomia has m ...

(seen in a variant of

Guillain–Barré syndrome Guillain–Barré syndrome (GBS) is a rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system. Typically, both sides of the body are involved, and the initial symptoms are changes in sensation or pain often ...

) *Toxin, drug or infection-induced

neuropathy Peripheral neuropathy, often shortened to neuropathy, is a general term describing disease affecting the peripheral nerves, meaning nerves beyond the brain and spinal cord. Damage to peripheral nerves may impair sensation, movement, gland, or o ...

Non-neurally mediated causes include: *Medications (

antihypertensive Antihypertensives are a class of drugs that are used to treat hypertension (high blood pressure). Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke and myocardial infarction. Evidence suggests tha ...

vasodilator Vasodilation is the widening of blood vessels. It results from relaxation of smooth muscle cells within the vessel walls, in particular in the large veins, large arteries, and smaller arterioles. The process is the opposite of vasoconstriction, ...

s) *Decreased

blood volume Blood volume (volemia) is the volume of blood (blood cells and plasma) in the circulatory system of any individual. Humans A typical adult has a blood volume of approximately 5 liters, with females and males having approximately the same blood per ...

(

adrenal insufficiency Adrenal insufficiency is a condition in which the adrenal glands do not produce adequate amounts of steroid hormones. The adrenal gland normally secretes glucocorticoids (primarily cortisol), mineralocorticoids (primarily aldosterone), and androge ...

blood loss Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

dehydration In physiology, dehydration is a lack of total body water, with an accompanying disruption of metabolic processes. It occurs when free water loss exceeds free water intake, usually due to exercise, disease, or high environmental temperature. Mil ...

or decreased effective intravascular volume) * Physical deconditioning *

Sympathectomy A sympathectomy is an irreversible procedure during which at least one sympathetic ganglion is removed. One example is the lumbar sympathectomy, which is advised for occlusive arterial disease in which L2 and L3 ganglia along with intervening sym ...

Pathophysiology

The

autonomic nervous system The autonomic nervous system (ANS), formerly referred to as the vegetative nervous system, is a division of the peripheral nervous system that supplies viscera, internal organs, smooth muscle and glands. The autonomic nervous system is a control ...

regulates various body processes and comprises the sympathetic (

adrenergic Adrenergic means "working on adrenaline (epinephrine) or noradrenaline (norepinephrine)" (or on their receptors). When not further qualified, it is usually used in the sense of enhancing or mimicking the effects of epinephrine and norepinephrine in ...

) and

parasympathetic The parasympathetic nervous system (PSNS) is one of the three divisions of the autonomic nervous system, the others being the sympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of t ...

(

cholinergic Cholinergic agents are compounds which mimic the action of acetylcholine and/or butyrylcholine. In general, the word "choline" describes the various quaternary ammonium salts containing the ''N'',''N'',''N''-trimethylethanolammonium cation. F ...

)

nervous system In biology, the nervous system is the highly complex part of an animal that coordinates its actions and sensory information by transmitting signals to and from different parts of its body. The nervous system detects environmental changes th ...

. These systems work in balance to respond to changes throughout the body. When the body assumes an upright position, there is an immediate gravitational pooling of about 500 to 1000ml of blood to the lower extremities,

splanchnic Splanchnic is usually used to describe organs in the abdominal cavity. It is used when describing: * Splanchnic tissue * Splanchnic organs - including the stomach, small intestine, large intestine, pancreas, spleen, liver, and may also include the ...

and

pulmonary circulation The pulmonary circulation is a division of the circulatory system in all vertebrates. The circuit begins with deoxygenated blood returned from the body to the right atrium of the heart where it is pumped out from the right ventricle to the lungs. ...

s. The decrease in

venous Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...

return to the heart reduces

cardiac output In cardiac physiology, cardiac output (CO), also known as heart output and often denoted by the symbols Q, \dot Q, or \dot Q_ , edited by Catherine E. Williamson, Phillip Bennett is the volumetric flow rate of the heart's pumping output: t ...

and eventually causes a drop in blood pressure.

Baroreceptor Baroreceptors (or archaically, pressoreceptors) are sensors located in the carotid sinus (at the bifurcation of external and internal carotids) and in the aortic arch. They sense the blood pressure and relay the information to the brain, so that a ...

s in the

carotid In anatomy, the left and right common carotid arteries (carotids) (Entry "carotid"
in
aortic arteries sense this decrease in blood pressure and activate the

sympathetic nervous system The sympathetic nervous system (SNS) is one of the three divisions of the autonomic nervous system, the others being the parasympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of th ...

which leads to increased

, systemic vasoconstriction, and increased cardiac muscle contractility all of which eventually increase blood pressure. In a healthy individual, this sympathetic activation causes a physiological increase in heart rate by 10 to 20 bpm,

diastolic blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...

by 5mmHg, but minimal to no change in

systolic blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...

. In patients with

autonomic dysfunction Dysautonomia or autonomic dysfunction is a condition in which the autonomic nervous system (ANS) does not work properly. This may affect the functioning of the heart, bladder, intestines, sweat glands, pupils, and blood vessels. Dysautonomia has ...

, there is an inadequate engagement of the autonomic nervous system in response to a decrease in blood pressure leading to persistent hypotension.

Diagnosis

Orthostatic vitals including blood pressure and heart rate in response to upright posture for at least 3 minutes is essential for the diagnosis of orthostatic syncope. A resting 12-lead electrocardiogram is useful to rule out

s. Targeted blood testing is reasonable including complete

hematology Hematology ( always spelled haematology in British English) is the branch of medicine concerned with the study of the cause, prognosis, treatment, and prevention of diseases related to blood. It involves treating diseases that affect the produc ...

glycemic The glycemic response to a food or meal is the effect that food or meal has on blood sugar (glucose) levels after consumption.Sadler M. Food, Glycaemic Response and Health. ILSI Europe Concise Monograph Series 2011:1-30Available from ILSI Europe ...

and

metabolic Metabolism (, from el, μεταβολή ''metabolē'', "change") is the set of life-sustaining chemical reactions in organisms. The three main functions of metabolism are: the conversion of the energy in food to energy available to run cell ...

profiles to rule out associated conditions such as

anemia Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...

or renal derangements. In selected patients with suspected

neurodegenerative disease A neurodegenerative disease is caused by the progressive loss of structure or function of neurons, in the process known as neurodegeneration. Such neuronal damage may ultimately involve cell death. Neurodegenerative diseases include amyotrophic ...

and syncope, referral for autonomic evaluation is reasonable to improve diagnostic and prognostic accuracy.

Differential Diagnosis

Differential diagnosis includes other causes of

loss of consciousness Loss may refer to: Arts, entertainment, and media Music * ''Loss'' (Bass Communion album) (2006) * ''Loss'' (Mull Historical Society album) (2001) *"Loss", a song by God Is an Astronaut from their self-titled album (2008) * Losses "(Lil Tjay son ...

Seizure An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with los ...

s *

Hypoglycemia Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose belo ...

Concussion A concussion, also known as a mild traumatic brain injury (mTBI), is a head injury that temporarily affects brain functioning. Symptoms may include loss of consciousness (LOC); memory loss; headaches; difficulty with thinking, concentration, ...

secondary to

head trauma A head injury is any injury that results in trauma to the skull or brain. The terms ''traumatic brain injury'' and ''head injury'' are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of inju ...

Drug A drug is any chemical substance that causes a change in an organism's physiology or psychology when consumed. Drugs are typically distinguished from food and substances that provide nutritional support. Consumption of drugs can be via insuffla ...

alcohol intoxication Alcohol intoxication, also known as alcohol poisoning, commonly described as drunkenness or inebriation, is the negative behavior and physical effects caused by a recent consumption of alcohol. In addition to the toxicity of ethanol, the main p ...

* Metabolic conditions including

hypothyroidism Hypothyroidism (also called ''underactive thyroid'', ''low thyroid'' or ''hypothyreosis'') is a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. It can cause a number of symptoms, such as po ...

hypoxemia Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the body ...

Management

The history and physical examination are essential components in the evaluation of a patient with orthostatic syncope. The history may reveal a cause for

such as

vomiting Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the Human nose, nose. Vomiting can be the result of ailments like Food-poisoning, foo ...

diarrhea Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin wi ...

, and decreased oral intake.

Melena Melena or melaena refers to the dark black, tarry feces that are associated with upper gastrointestinal bleeding. The black color and characteristic strong odor are caused by hemoglobin in the blood being altered by digestive enzymes and intest ...

hematemesis Hematemesis is the vomiting of blood. It is always an important sign. It can be confused with hemoptysis (coughing up blood) or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically abo ...

hematuria Hematuria or haematuria is defined as the presence of blood or red blood cells in the urine. “Gross hematuria” occurs when urine appears red, brown, or tea-colored due to the presence of blood. Hematuria may also be subtle and only detectable w ...

menorrhagia Heavy menstrual bleeding (HMB), previously known as menorrhagia or hypermenorrhea, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding Abnormal uterine bleeding (AUB), also known as (AVB) or as atypical ...

hematochezia Haematochezia is the passage of fresh blood through the anus path, usually in or with stools (contrast with melena). The term is from Greek αἷμα ("blood") and χέζειν ("to defaecate"). Hematochezia is commonly associated with lower gastro ...

point to blood loss. Elderly deconditioned patients, especially after prolonged

hospitalization A hospital is a health care institution providing patient treatment with specialized Medical Science, health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically ...

, may have reduced

muscle tone In physiology, medicine, and anatomy, muscle tone (residual muscle tension or tonus) is the continuous and passive partial muscle contraction, contraction of the muscles, or the muscle's resistance to passive stretch during resting state.O’Sull ...

. Review of the patients' medication list may show

polypharmacy Polypharmacy (polypragmasia) is the simultaneous use of multiple medicines by a patient for their conditions. Most commonly it is defined as regularly taking five or more medicines but definitions vary in where they draw the line for the minimum ...

, culprit medications (including

diuretics A diuretic () is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics in ...

s, other

s) and

steroid A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...

s (a clue to steroid-induced

). Review of the past medical history will reveal associated predisposing medical conditions ( diabetes,

Parkinsonism Parkinsonism is a clinical syndrome characterized by tremor, bradykinesia (slowed movements), rigidity, and postural instability. These are the four motor symptoms found in Parkinson's disease (PD), after which it is named, dementia with Lewy bo ...

dementia Dementia is a disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease. The symptoms involve progressive impairments in memory, thinking, and behavior, which negatively affe ...

). Patient compliance with both pharmacological and nonpharmacological therapy is recommended for successful treatment. Treatment of orthostatic syncope depends on the underlying cause and includes both nonpharmacological and pharmacological measures. Nonpharmacological treatment measures aim at either increasing

venous return Venous return is the rate of blood flow back to the heart. It normally limits cardiac output. Superposition of the cardiac function curve and venous return curve is used in one hemodynamic model. __TOC__ Physiology Venous return (VR) is the flow o ...

to the heart while decreasing venous pooling in the lower extremities or increasing

to maintain blood pressure in the

supine position The supine position ( or ) means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it grants access to the peritoneal, thoracic and pericardial regions; ...

and include: #Avoiding physical deconditioning in the elderly which helps maintain muscle tone in lower extremities # External compression devices such as waist-high compression stockings, abdominal binders # Physical maneuvers such as lunges, calf-raise,

squatting Squatting is the action of occupying an abandoned or unoccupied area of land or a building, usually residential, that the squatter does not own, rent or otherwise have lawful permission to use. The United Nations estimated in 2003 that there ...

, leg crossing #Review of home medications and discontinue diuretics and vasodilators if possible #Increase

water Water (chemical formula ) is an inorganic, transparent, tasteless, odorless, and nearly colorless chemical substance, which is the main constituent of Earth's hydrosphere and the fluids of all known living organisms (in which it acts as a ...

and fluid intake to about 2-3 liters per day, avoid

, bolus water ingestion of 500mls of water in 2 to 3 minutes especially in the

morning Morning is the period from sunrise to noon. There are no exact times for when morning begins (also true of evening and night) because it can vary according to one's lifestyle and the hours of daylight at each time of year. However, morning strict ...

#Dietary measures including liberal salt diet 6-10g/day, eating small frequent low carbohydrate meals a day in case of postprandial orthostatic hypotension, avoid alcohol intake #In patients with

and

supine hypertension Supine hypertension is a paradoxical elevation in blood pressure upon assuming a supine position from a standing or sitting position. It is assumed to be a manifestation of disorders of the autonomic nervous system or due to side effects of medicati ...

, raising the head of the bed to 10 degrees at night reduces nocturnal diuresis #Life style modification by avoiding activities that increase

core temperature Normal human body-temperature (normothermia, euthermia) is the typical temperature range found in humans. The normal human body temperature range is typically stated as . Human body temperature varies. It depends on sex, age, time of day, exert ...

and cause peripheral vasodilatation such as avoiding

sauna A sauna (, ), or sudatory, is a small room or building designed as a place to experience dry or wet heat sessions, or an establishment with one or more of these facilities. The steam and high heat make the bathers perspire. A thermometer in a ...

spa A spa is a location where mineral-rich spring water (and sometimes seawater) is used to give medicinal baths. Spa towns or spa resorts (including hot springs resorts) typically offer various health treatments, which are also known as balneoth ...

s, hot tubs, prolonged hot showers, and excessive high-intensity exercise The goal of pharmacological treatment is to increase blood volume or peripheral vascular resistance and includes: #

Midodrine Midodrine is a vasopressor/antihypotensive agent (it raises the blood pressure). Midodrine was approved in the United States by the Food and Drug Administration (FDA) in 1996 for the treatment of dysautonomia and orthostatic hypotension. In A ...

2.5 to 15 mg orally once to thrice daily #

Fludrocortisone Fludrocortisone, sold under the brand name Florinef, among others, is a corticosteroid used to treat adrenogenital syndrome, postural hypotension, and adrenal insufficiency. In adrenal insufficiency, it is generally taken together with hydroco ...

0.1 to 0.2 mg

daily Daily or The Daily may refer to: Journalism * Daily newspaper, newspaper issued on five to seven day of most weeks * ''The Daily'' (podcast), a podcast by ''The New York Times'' * ''The Daily'' (News Corporation), a defunct US-based iPad new ...

in the morning titrated up to 1 mg daily if needed #

Pyridostigmine Pyridostigmine is a medication used to treat myasthenia gravis and underactive bladder. It is also used together with atropine to end the effects of neuromuscular blocking medication of the non-depolarizing type. It is typically given by mouth ...

30 to 60 mg orally trice daily #

Yohimbine Yohimbine (), also known as quebrachine, is an indole alkaloid derived from the bark of the African tree ''Pausinystalia johimbe''; also from the bark of the unrelated South American tree ''Aspidosperma quebracho-blanco''. Yohimbine is an α2- ...

5.4 to 10.8 mg orally trice daily #

Octreotide Octreotide, sold under the brand name Sandostatin among others, is an octapeptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone. It was ...

12.5 to 50 ug subcutaneously twice daily #

Cafergot Caffeine/ergotamine (trade name Cafergot) is the proprietary name of a medication consisting of ergotamine tartrate and caffeine. This combination is used for the treatment of headaches, such as migraine headache. Use Correct timing of use is ...

such as

caffeine Caffeine is a central nervous system (CNS) stimulant of the methylxanthine class. It is mainly used recreationally as a cognitive enhancer, increasing alertness and attentional performance. Caffeine acts by blocking binding of adenosine t ...

100 mg and

ergotamine Ergotamine, sold under the brand names Cafergot (with caffeine) and Ergomar among others, is an ergopeptine and part of the ergot family of alkaloids; it is structurally and biochemically closely related to ergoline. It possesses structural simil ...

100 mg

Prognosis

Prognosis for orthostatic syncope depends on the underlying cause of orthostatic hypotension. The prognosis is good in non-neurally mediated orthostatic syncope once the cause of postural hypotension is identified and treated -

fluid resuscitation Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous ...

volume depletion Hypovolemia, also known as volume depletion or volume contraction, is a state of abnormally low extracellular fluid in the body. This may be due to either a loss of both salt and water or a decrease in blood volume. Hypovolemia refers to the los ...

, transfusion for blood loss, discontinuation of offending antihypertensive medications. In neurally mediated syncope, prognosis depends on the course of the underlying medical condition. However, in the Framingham heart study, patients with syncope of unknown cause or neurologic syncope had an increased risk of death from any cause in multivariable-adjusted

hazard ratio In survival analysis, the hazard ratio (HR) is the ratio of the hazard rates corresponding to the conditions characterised by two distinct levels of a treatment variable of interest. For example, in a clinical study of a drug, the treated populati ...

s of 1.32 and 1.54 respectively. Orthostatic hypotension is one of the most frequently identified causes of syncope in the general population. Effective treatment depends on determining the underlying etiology and instituting appropriate interventions to reduce the risk of harm to the patient. If the history suggests neurogenic orthostatic hypotension as a cause of syncope, a definitive diagnosis may require a ''complete autonomic workup and coordination of care'' between the

primary care provider Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care th ...

cardiologist Cardiology () is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular hear ...

, and

neurologist Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal c ...

Epidemiology

Orthostatic hypotension is more frequent in elderly patients because of multiple factors such as

, age-related changes in baroreflexes and

vasoconstrictor Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, in particular the large arteries and small arterioles. The process is the opposite of vasodilation, the widening of blood vessel ...

responses and a decrease in

, cardiac and vascular compliance. Neurogenic orthostatic hypotension showed a prevalence of 18% in patients older than 65 years and resulted in syncope in 9.4% of patients in the NIH funded Framingham cohort.

References

{{reflist Hypotension