EFNS guidelines on the diagnosis and management of orthostatic hypotension

Abstract

Orthostatic (postural) hypotension (OH) is a common, yet under diagnosed disorder. It may contribute to disability and even death. It can be the initial sign, and lead to incapacitating symptoms in primary and secondary autonomic disorders. These range from visual disturbances and dizziness to loss of consciousness (syncope) after postural change. Evidence based guidelines for the diagnostic workup and the therapeutic management (non-pharmacological and pharmacological) are provided based on the EFNS guidance regulations. The final literature research was performed in March 2005. For diagnosis of OH, a structured history taking and measurement of blood pressure (BP) and heart rate in supine and upright position are necessary. OH is defined as fall in systolic BP below 20 mmHg and diastolic BP below 10 mmHg of baseline within 3 min in upright position. Passive head-up tilt testing is recommended if the active standing test is negative, especially if the history is suggestive of OH, or in patients with motor impairment. The management initially consists of education, advice and training on various factors that influence blood pressure. Increased water and salt ingestion effectively improves OH. Physical measures include leg crossing, squatting, elastic abdominal binders and stockings, and careful exercise. Fludrocortisone is a valuable starter drug. Second line drugs include sympathomimetics, such as midodrine, ephedrine, or dihydroxyphenylserine. Supine hypertension has to be considered.

Application of the Sit-Up Test for orthostatic hypotension in individuals with stroke

“…The Sit-Up Test is easy to administer in the clinical setting, provided that staff are appropriately trained to recognize and respond to symptoms. Guidelines recommend that resuscitation and cardiac life support procedures are in place prior to an orthostatic challenge test (Lahrmann et al, 2006). For safety, we performed this test with two examiners, although it is possible for it to be done by one trained assessor, providing they are able to safely complete the passive maneuver from supine to sitting, while monitoring for hypotensive symptoms.…”

Prevalence and Clinical Implications of Orthostatic Hypotension in Elderly Inpatients

“…BP measurements were made during the day at least thirty minutes after meals. The cardiovascular response was investigated by recording the peripheral heart rate whilst supine and upright as suggested by the current European OH guidelines [30].…”

Hemodynamic responses to head-up tilt after spinal cord injury support a role for the mid-thoracic spinal cord in cardiovascular regulation

“…For example: (a) orthostatic hypotension in a person with chronic T 4 -T 6 paraplegia should raise suspicion of an additional lesion because of the observed mild or transient nature of BP response to HUT in T 4 -T 6 SCI patients; (b) if the observation is confirmed, orthostatic hypotension in these patients, which is usually mild if present, may be treated with nonpharmacological measures, avoiding at least part of the measures recommended by the European Federation of Neurological Societies (EFNS) guidelines for the management of orthostatic hypotension; 19 (c) the mid-thoracic neural mechanism suggested by this study indirectly supports the minimal autonomic hyper-reflexia expression in patients with T 4 -T 6 SCI, demonstrated in another publication. 8 Limitations Limitations of the study include an absence of anatomically complete lesions, multiple analyses, a relatively small study population, a possible effect of respiration during HUT on findings and possible minor errors in the non-invasive BP measurement.…”