What is the minimum duration of head-up tilt necessary to detect orthostatic hypotension? (original) (raw)

Abstract

Objective

There is uncertainty as to the minimum duration of head-up tilt (HUT) needed to detect orthostatic hypotension (OH). The orthostatic duration has variably been recommended to be 1, 2, 3, and 5 minutes. The purpose of the current study was 1) to determine the minimum duration of HUT necessary to detect OH and 2) to identify different patterns of orthostatic blood pressure (BP) response in patients with OH.

Design/methods

We evaluated the medical records of 66 consecutive patients (mean age 70.0±10.1 years; 64% male) seen at Mayo Clinic-Rochester from 2000–2001 who fulfilled the criteria for OH (systolic blood pressure [SBP] reduction ≥ 20mm Hg within 3 minutes of HUT) during routine clinical autonomic studies. All patients completed an autonomic reflex screen with continuous monitoring of heart rate and BP during supine rest and 5 minutes of 70 degree HUT. Severity of autonomic deficits was quantified with the Composite Autonomic Severity Score (CASS).

Results

Overall, BP was the lowest at 1 minute with gradual and partial recovery over the following 4 minutes. Eighty-eight percent of patients (N=58) developed OH by 1 minute of HUT, with an additional 11% (N=7) developing OH by 2 minutes and the remaining 1% (N=1) developing OH by 3 minutes. We identified two broad patterns of SBP response to HUT. Forty-eight percent (N=32) of patients demonstrated an initial drop in SBP (≥ 20 mm Hg),which remained stable until tilt-back. Thirty-six percent (N=24) demonstrated an initial drop (≥ 20mm Hg) followed by a progressive decline in SBP until tilt-back. Repeated measures analysis of variance confirmed that the SBP change in response to HUT differed significantly among patients with a stable vs. progressive pattern [F(3,32)=25.1, p<0.001). Patients with the progressive pattern also had more severe adrenergic impairment on the CASS (p=0.03) and were more likely to have their tilt test terminated early (prior to 5minutes) due to presyncope (p<0.0001) than patients with the stable pattern.

Conclusions

One minute of HUT will detect OH in the great majority (88%) of patients and three minutes will detect the balance. Orthostatic stress beyond 2 minutes is necessary to detect the pattern of progressive OH. Since this group has more severe adrenergic deficits than the group with stable OH, we suggest that the progressive pattern is due to greater impairment of compensatory reflexes. Recognition of the group with progressive fall in BP is important since this group may be at greater risk of orthostatic syncope.

Access this article

Log in via an institution

Subscribe and save

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Anonymous (1996) Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Neurology 46:1470
    Google Scholar
  2. Gilman S, Low PA, Quinn N, Albanese A, Ben-Schlomo Y, Fowler CJ, Kaufmann H, Klockgether T, Lang AE, Lantos PL, Litvan I, Mathias CJ, Oliver E, Robertson D, Schatz I, Wenning GK (1998) Consensus statement on the diagnosis of multiple system atrophy. J Auton Nerv Syst 74:189–192
    Google Scholar
  3. Kaufmann H (1995) Neurally mediated syncope: Pathogenesis, diagnosis, and treatment. Neurology 45:S12–S18
    Google Scholar
  4. Low PA (1993) Composite autonomic scoring scale for laboratory quantification of generalized autonomic failure. Mayo Clin Proc 68:748–752
    Google Scholar
  5. Low PA (1993) Neurogenic orthostatic hypotension. In: Johnson RT, Griffin JW (eds) Current Therapy in Neurologic Disease. Mosby-Year Book, Inc., St. Louis, pp 21–26
  6. Low PA(1994) Neurogenic orthostatic hypotension. In: Johnson R (ed) Current Therapy in Neurologic Disease. Mosby Year Book, Philadelphia
  7. Low PA(1997) Laboratory evaluation of autonomic function. In: Low PA (ed) Clinical Autonomic Disorders: Evaluation and Management. Lippincott-Raven, Philadelphia, pp 179–208
  8. Low PA, Gilden JL, Freeman R, Sheng KN, McElligott MA (1997) Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, double-blind multicenter study. Midodrine Study Group. JAMA 277:1046–1051
    Google Scholar
  9. Robertson D, Davis TL (1995) Recent advances in the treatment of orthostatic hypotension. Neurology 45:S26–S32
    Google Scholar
  10. Smit AAJ, Halliwill JR, Low PA, Wieling W (1999) Pathophysiological basis of orthostatic hypotension in autonomic failure. J Physiol 519:1–10
    Google Scholar
  11. Spies JM, Novak V, Gordon VM, Petty GW, Novak P, Lagerlund TD, Low PA (1998) Cerebral autoregulation in the postural tachycardia syndrome (POTS) and orthostatic hypotension (OH). Neurology 50(Suppl 4):A239
    Google Scholar

Download references

Author information

Authors and Affiliations

  1. Dept. of Neurology, Mayo Clinic, Rochester (MN), USA
    Jade A. Gehrking, Stacy M. Hines, Lisa M. Benrud-Larson, Tonette L. Opher-Gehrking & Phillip A. Low M. D.
  2. Mayo Clinic, 200 First Street,SW, Rochester (MN) 55095, USA
    Phillip A. Low M. D.

Authors

  1. Jade A. Gehrking
    You can also search for this author inPubMed Google Scholar
  2. Stacy M. Hines
    You can also search for this author inPubMed Google Scholar
  3. Lisa M. Benrud-Larson
    You can also search for this author inPubMed Google Scholar
  4. Tonette L. Opher-Gehrking
    You can also search for this author inPubMed Google Scholar
  5. Phillip A. Low M. D.
    You can also search for this author inPubMed Google Scholar

Corresponding author

Correspondence toPhillip A. Low M. D..

Rights and permissions

About this article

Cite this article

Gehrking, J.A., Hines, S.M., Benrud-Larson, L.M. et al. What is the minimum duration of head-up tilt necessary to detect orthostatic hypotension?.Clin Auton Res 15, 71–75 (2005). https://doi.org/10.1007/s10286-005-0246-y

Download citation

Key words