There seems to be a controversy around the usefulness of obtaining orthostatic blood pressures on those patients who present to the ED with syncope after all other causes of syncope have been relatively ruled out. Also, does anyone have any specific and/or validated protocols for the time differential between each measurement? Also, what is the definition (based on the measurements) of orthostatic hypotension and are there any protocols on the treatment for a patient that has been determined to be positive for orthostatic hypotension? Is there an accepted algorithm for the amount of fluid bolus that is specifically titrated to the actual findings of the orthostatic measurements?
yes, it is very important to measure blood pressure several times!
I would say, "you cannot dismiss your patient without having measured orthostatic blood pressure AND heart rate". There is a range of autonomic disorders that all may lead to orthostatic intolerance (if that is the established cause of the syncope).
Much more on diagnosis and treatment in two books on the subject:
Clinical Autonomic Disorders by Phillip A. Low and Eduardo E. Benarroch (Eds)
and:
Autonomic Failure by Christopher J. Mathias and Sir Roger Bannister (Eds)
It is essential as OH is an important cause of syncope and it can be readily diagnosed in this way. If you care to do a tilt test on all you will do even better but this is not necessary.
The previous answers show an agreement about the usefulness of measuring ortostatic pressure in patients showing syncopal events. I fully agree with this point of view and appreciate the emphasis given by Dr. Karemaker. In general, syncopal events are the consequences of a reduced cardiac output, which in turn may depend either on a seriously reduced heart rate, as e.g in the Morgagni, Adams and Stokes syndrome, or on a reduced venous return, as in the case of an increased venous capacity, due, eg, tovenous varocosities or venous reduced parietal tone.
A simple physical examination of a patients with syncopal events must include measurement of both heart rate and ortostatic pressure. Since these two variables are intimately connected together because of the role of heart rate in cardiac output and of the behavior of baroreceptors after changes of the arterial blood pressure, it is necessary to measure both..
A procedure, which in my opinion should be useful, is to measure heart rate and blood pressure with the patient in clinostatic position, then to ask him to arise rapidly to ortostatism and repeat the measurements. If the venous return is really impaired it is possible to observe a reduction of blood pressure (ortostatic hypotension) because of the increase of the blood pool in the veins and an increase in heart rate due to the reduced cardiac vagal tone in response to the reduced baroreceptor stimulation. If a compensation occurs, further measurements in standing position would reveal a more or less partial recovery of the pressure with an inversely proportional change in heart rate.
As far I can understand your question coud be divided in two points:
1) how to measure PH: simply after 1 and 2 minutes after standing and the cut off values are generally considered a drop of 20 mmHg ( or in other papers 30mmHg) . This is exesivly teated by P low as above cited. by JMKaremaker
2) When PH is usefull for diagnosing Syncope: quite seldom as a)Autonomic Neuropathy, b)Hypocortisolism, c) (rarely) Pheocromocytoma could be extimate to occur in less than 20% of cases of Syncope ( no definite data are avaiable) . Hence, the majority of cases of syncope are due to c) vasovagal, d) vasodepressive, e) neurological origin when PH does not occur. So, PH could be useful ( and not always) only in the cases a) b) c) .
Tilting could be more usefull....
Best wishes
Dear Wayne, you use our ZhGS formulas as additional parameters for optimal orthostatic blood pressure determination.
Dear Sir, It is not only a must but very important as Neurocardiogenic Syncope and Related Disorders of Orthostatic Intolerance is something you have to be aware of in which The ANS ( Autonomic nervous system ) is both complex and diverse and is involved in essentially every organ system and in the majority of disease processes. Disruptions in this system can be incredibly diverse in presentation, yet often culminate in a failure to maintain normotension, with resultant near syncope and syncope.
A working knowledge of these disorders is required for both their recognition and their management.
Further investigations will aid in our understanding of this wide range of disorders and at the same time identify better diagnostic and therapeutic modalities.
Recently, I happened to come to a restaurant where the waitress and 2 guests held an unconscious very old man with enuresis in an upright position. After he was positioned in a variant of the Trendelenburg position, he came to himself again. The discussion here offers some interesting points of view to diagnose and manage transient loss of consciousness (TLOC) in an emergency.
Article 2018 ESC Guidelines for the diagnosis and management of syncope
Measuring orthostatic blood pressures in patients with a syncopal event is of practical consequence, because with a drop in systolic blood pressure by ≥ 20 mmHg an imme-diate fluid intake may be indicated.
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