Syncope pp 179-197 | Cite as

Orthostatic Intolerance: Orthostatic Hypotension and Postural Orthostatic Tachycardia Syndrome

  • Michele Brignole
  • David G. Benditt


In health, movement from lying or sitting to standing is largely unassociated with evident change in well-being. However, in some individuals, especially those who are physically deconditioned, there may be a transient sense of increased heart rate. In others, a brief “grey-out” of vision may occur from time to time, but this sensation usually disappears quickly (perhaps <10 s) and does not occur consistently. On the other hand, if symptoms of near-syncope or syncope develop repetitively, or if patients begin to complain of symptoms suggestive of sympathetic autonomic hyperactivity (e.g., palpitations, heart racing, and anxiety) with movement to the upright posture, then they may be considered to be exhibiting orthostatic intolerance.


Chronic Fatigue Syndrome Orthostatic Hypotension Autonomic Failure Orthostatic Intolerance Pure Autonomic Failure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Schatz IJ, et al. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology. 46:1470 and Clin Autonom Res. 1996;6:125–126.CrossRefGoogle Scholar
  2. 2.
    Wieling W, Schatz IJ. The consensus statement on the definition of orthostatic hypotension: a revisit after 13 years. J Hypertens. 2009;27:935–938.PubMedCrossRefGoogle Scholar
  3. 3.
    Robertson D. The pathophysiology and diagnosis of orthostatic hypotension. Clin Autonom Res. 2008;18(Suppl 1):2–7.CrossRefGoogle Scholar
  4. 4.
    Low PA, et al. Postural tachycardia syndrome (POTS). J Cardiovasc Electrophysiol. 2009;20:352–358.PubMedCrossRefGoogle Scholar
  5. 5.
    Stewart JM. Chronic orthostatic intolerance and the postural tachycardia syndrome (POTS). J Pediatr. 2004;145:725–730.PubMedCrossRefGoogle Scholar
  6. 6.
    Joyner MJ, Masuki S. POTS versus deconditioning: the same or different? Clin Autonom Res. 2008;18:300–307.CrossRefGoogle Scholar
  7. 7.
    Davis BR, et al. The association of postural changes in systolic blood pressure and mortality in persons with hypertension. Circulation. 1987;75:340–346.PubMedCrossRefGoogle Scholar
  8. 8.
    Masaki KH, et al. Orthostatic hypotension predicts mortality in elderly men: the Honolulu Heart Program. Circulation. 1998;98:2290–2295.PubMedCrossRefGoogle Scholar
  9. 9.
    Federowski A. Orthostatic hypotension in genetically related hypertensive and normotensive subjects. J Hypertens. 2009;27:976–982.CrossRefGoogle Scholar
  10. 10.
    Mathias CJ. Autonomic diseases – clinical features and laboratory evaluation. J Neurol Neurosurg Psychiatr. 2003;74:31–41.Google Scholar
  11. 11.
    Mathias CJ. Autonomic diseases – management. J Neurol Neurosurg Psychiatr. 2003;74: 42–47.CrossRefGoogle Scholar
  12. 12.
    Mathias CJ. Disorders of the autonomic nervous system. In: Bradley WG, et al. (eds) Neurology in Clinical Practice (2004). 3rd edn. Boston, MA: Butterworth-Heinemann; 2003:pp 2403–2440.Google Scholar
  13. 13.
    Mathias CJ. To stand on one’s own legs. Clin Med. 2003;2:237–245.Google Scholar
  14. 14.
    Smit AAJ, et al. Topical review. Pathophysiological basis of orthostatic hypotension in autonomic failure. J Physiol. 1999;519:1–10.PubMedCrossRefGoogle Scholar
  15. 15.
    Lahrmann H, et al. EFNS guidelines on the diagnosis and management of orthostatic hypotension. Eur J Neurol. 2006;13:930–936.PubMedCrossRefGoogle Scholar
  16. 16.
    Freeman R. Neurogenic orthostatic hypotension. N Engl J Med. 2008;358:615–624.PubMedCrossRefGoogle Scholar
  17. 17.
    Wieling W, et al. Initial hypotension: review of a forgotten condition. Clin Sci. 2007;112: 157–165.PubMedCrossRefGoogle Scholar
  18. 18.
    Low PA, et al. Prospective evaluation of clinical characteristics of orthostatic hypotension. Mayo Clin Proc. 1995;70:617–622.PubMedCrossRefGoogle Scholar
  19. 21.
    Mathias CJ, et al. Observations on recurrent syncope and presyncope in 641 patients. Lancet. 2001;357:348–353.PubMedCrossRefGoogle Scholar
  20. 19.
    Lipsitz LA. Orthostatic hypotension in the elderly. N Engl J Med. 1989;321:952–957.PubMedCrossRefGoogle Scholar
  21. 20.
    Rutan GH, et al. Orthostatic hypotension in older adults. The Cardiovascular Health Study. Hypertension. 1992;9:508–519.CrossRefGoogle Scholar
  22. 22.
    Stewart JM, et al. Defects in cutaneous angiotensin-converting enzyme 2 and angiotensin-(1–7) production in postural tachycardia syndrome. Hypertension. 2009;53:767–774.PubMedCrossRefGoogle Scholar
  23. 23.
    Sandroni P, Low PA. Other autonomic neuropathies associated with ganglionic antibody. Auton Neurosci. 2009;146:13–17.PubMedCrossRefGoogle Scholar
  24. 24.
    El-Sayed H, Hainsworth R. Relationship between plasma volume, carotid baroreceptor sensitivity and orthostatic tolerance. Clin Sci. 1995;88:463–470.PubMedGoogle Scholar
  25. 25.
    Wieling W, et al. Extracellular fluid volume expansion in patients with posturally related syncope. Clin Autonom Res. 2002;12:243–249.Google Scholar
  26. 26.
    Wieling W, et al. Physical manoeuvres that reduce postural hypotension in autonomic failure. Clin Autonom Res. 1993;3:57–65.CrossRefGoogle Scholar
  27. 27.
    van Dijk N, et al. Hemodynamic effects of leg crossing and skeletal muscle tensing during free standing in patients with vasovagal syncope. J Appl Physiol. 2005;98:584–590.PubMedCrossRefGoogle Scholar
  28. 28.
    Krediet CT, et al. Management of vasovagal syncope: Controlling or aborting faints by leg crossing and muscle tensing. Circulation. 2002;106:1684–1689.PubMedCrossRefGoogle Scholar
  29. 29.
    Brignole M, et al. Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope. J Am Coll Cardiol. 2002;40:2053–2059.PubMedCrossRefGoogle Scholar
  30. 30.
    Reybrouck T, et al. Long-term follow-up results of tilt training therapy in patients with recurrent neurocardiogenic syncope. Pacing Clin Electrophysiol. 2002;25:1441–1446.PubMedCrossRefGoogle Scholar
  31. 31.
    Podoleanu C, et al. Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons a randomized single-blind controlled study. J Am Coll Cardiol. 2006;48:1425–1432.PubMedCrossRefGoogle Scholar
  32. 32.
    Hussain RM, et al. Fludrocortisone in the treatment of hypotensive disorders in the elderly. Heart. 1996;76:507–509.PubMedCrossRefGoogle Scholar
  33. 33.
    Claydon VE, Hainsworth R. Salt supplementation improves orthostatic cerebral and peripheral vascular control in patients with syncope. Hypertension. 2004;43:809–813.PubMedCrossRefGoogle Scholar
  34. 34.
    Low PA, et al. Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, double-blind multicenter study. J Am Med Assoc. 1997;277:1046–1051.CrossRefGoogle Scholar
  35. 35.
    Lai CC, et al. Outcomes in adolescents with postural orthostatic tachycardia syndrome treated with midodrine and beta-blockers. Pacing Clin Electrophysiol. 2009;32:234–238.PubMedCrossRefGoogle Scholar
  36. 36.
    Raj SR, et al. Propranolol decreases tachycardia and improves symptoms in the postural tachycardia syndrome: less is more. Circulation. 2009;120:725–734.PubMedCrossRefGoogle Scholar
  37. 37.
    Singer W, et al. Pyridostigmine treatment trial in neurogenic orthostatic hypotension. Arch Neurol. 2006;63:513–518.PubMedCrossRefGoogle Scholar
  38. 38.
    Cariga P, Mathias CJ. Haemodynamics of the pressor effect of oral water in human sympathetic denervation due to autonomic failure. Clin Sci. 2001;101:313–319.PubMedCrossRefGoogle Scholar
  39. 39.
    Young TM, Mathias CJ. The effects of water ingestion on orthostatic hypotension in two groups of chronic autonomic failure: Multiple system atrophy and pure autonomic failure. J Neurol Neurosurg Psychiatry. 2004;75:1737–1741.PubMedCrossRefGoogle Scholar
  40. 40.
    Melby DP, et al. Increased impedance to inspiration ameliorates hemodynamic changes associated with movement to upright posture in orthostatic hypotension: A randomized pilot study. Heart Rhythm. 2007;4:128–135.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2011

Authors and Affiliations

  1. 1.Dipartimento di Cardiologia, Centro AritmologicoOspedali del TigullioLavagnaItaly
  2. 2.Cardiac Arrhythmia CenterMedical School, University of MinnesotaMinneapolisUSA

Personalised recommendations