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Aetiology and haemodynamic patterns of orthostatic hypotension in a tertiary syncope unit

Johansson, Madeleine LU orcid ; Gagaouzova, Boriana S ; van Rossum, Ineke A ; Thijs, Roland D ; Hamrefors, Viktor LU orcid ; van Dijk, J Gert and Fedorowski, Artur LU orcid (2025) In Europace
Abstract
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Aims

Orthostatic hypotension (OH) is an important differential diagnosis in unexplained syncope. Neurogenic OH (nOH) has been postulated to differ from non-neurogenic OH (non-nOH), yet pathophysiological differences are largely unexplored. We aimed to investigate aetiology and tilt table test (TTT)-induced haemodynamic responses in symptomatic OH patients.

Methods and results

We performed a retrospective study analysing patients referred for unexplained syncope or highly symptomatic orthostatic intolerance with TTT-verified classical OH (cOH). Medical records were analysed for the presumptive aetiology of cOH. Fifty-two patients (mean age 73 ± 9 years, 46% women) with good quality TTT recordings were divided into three groups on clinical grounds: nOH, non-nOH, and mixed OH. The log-ratio (LR) method was applied to compare the decrease in mean arterial pressure (MAPLR) and corresponding contributions of heart rate (HRLR), stroke volume (SVLR), and total peripheral resistance (TPRLR) during the upright phase of TTT. The prevalence of cOH was 12 (23%) nOH, 14 (27%) non-nOH, and 26 (50%) mixed OH. No difference in MAPLR was observed among the three groups during the 4th upright minute of TTT (nOH: −0.10 ± 0.04 vs. non-nOH: −0.07 ± 0.05 and vs. mixed OH: −0.06 ± 0.05, P = 0.10). The contributions of HRLR, SVLR, and TPRLR to the drop in MAPLR did not differ between groups (all P > 0.05).

Conclusion

One-half of highly symptomatic OH patients had mixed OH, whereas one-quarter had either pure neurogenic or non-neurogenic OH, respectively. Different forms of OH were indifferentiable based on haemodynamic responses during TTT, questioning the clinical utility of such classification. Larger studies are needed to confirm these findings.

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organization
publishing date
type
Contribution to journal
publication status
epub
subject
keywords
orthostatic hypotension
in
Europace
publisher
Oxford University Press
external identifiers
  • pmid:39821313
ISSN
1532-2092
DOI
10.1093/europace/euaf017
language
English
LU publication?
yes
id
4213e403-e860-4350-a9b6-c02d7e95ee72
date added to LUP
2025-01-18 18:59:38
date last changed
2025-05-21 13:21:11
@article{4213e403-e860-4350-a9b6-c02d7e95ee72,
  abstract     = {{<div class="sec" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-variant-alternates: inherit; font-variant-position: inherit; font-variant-emoji: inherit; font-stretch: inherit; font-size: medium; line-height: inherit; font-family: Merriweather, serif; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline; color: rgb(42, 42, 42);"><div class="title" style="box-sizing: border-box; margin: 0px 0px 0.6rem; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: 700; font-stretch: inherit; font-size: 19px; line-height: inherit; font-family: &quot;Source Sans Pro&quot;, Helvetica, Arial, sans-serif; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline;">Aims</div><p class="chapter-para" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; font-size: 15px; line-height: 1.7em; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline;">Orthostatic hypotension (OH) is an important differential diagnosis in unexplained syncope. Neurogenic OH (nOH) has been postulated to differ from non-neurogenic OH (non-nOH), yet pathophysiological differences are largely unexplored. We aimed to investigate aetiology and tilt table test (TTT)-induced haemodynamic responses in symptomatic OH patients.</p></div><div class="sec" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-variant-alternates: inherit; font-variant-position: inherit; font-variant-emoji: inherit; font-stretch: inherit; font-size: medium; line-height: inherit; font-family: Merriweather, serif; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline; color: rgb(42, 42, 42);"><div class="title" style="box-sizing: border-box; margin: 1rem 0px 0.6rem; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: 700; font-stretch: inherit; font-size: 19px; line-height: inherit; font-family: &quot;Source Sans Pro&quot;, Helvetica, Arial, sans-serif; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline;">Methods and results</div><p class="chapter-para" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; font-size: 15px; line-height: 1.7em; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline;">We performed a retrospective study analysing patients referred for unexplained syncope or highly symptomatic orthostatic intolerance with TTT-verified classical OH (cOH). Medical records were analysed for the presumptive aetiology of cOH. Fifty-two patients (mean age 73 ± 9 years, 46% women) with good quality TTT recordings were divided into three groups on clinical grounds: nOH, non-nOH, and mixed OH. The log-ratio (LR) method was applied to compare the decrease in mean arterial pressure (MAP<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub>) and corresponding contributions of heart rate (HR<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub>), stroke volume (SV<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub>), and total peripheral resistance (TPR<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub>) during the upright phase of TTT. The prevalence of cOH was 12 (23%) nOH, 14 (27%) non-nOH, and 26 (50%) mixed OH. No difference in MAP<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub> was observed among the three groups during the 4th upright minute of TTT (nOH: −0.10 ± 0.04 vs. non-nOH: −0.07 ± 0.05 and vs. mixed OH: −0.06 ± 0.05, <em style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-variant: inherit; font-weight: inherit; font-stretch: inherit; font-size: inherit; line-height: inherit; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline;">P</em> = 0.10). The contributions of HR<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub>, SV<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub>, and TPR<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub> to the drop in MAP<sub style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; font-size: 0.75rem; line-height: normal; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit;">LR</sub> did not differ between groups (all <em style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-variant: inherit; font-weight: inherit; font-stretch: inherit; font-size: inherit; line-height: inherit; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline;">P</em> &gt; 0.05).</p></div><div class="sec" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-variant-alternates: inherit; font-variant-position: inherit; font-variant-emoji: inherit; font-stretch: inherit; font-size: medium; line-height: inherit; font-family: Merriweather, serif; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline; color: rgb(42, 42, 42);"><div class="title" style="box-sizing: border-box; margin: 1rem 0px 0.6rem; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: 700; font-stretch: inherit; font-size: 19px; line-height: inherit; font-family: &quot;Source Sans Pro&quot;, Helvetica, Arial, sans-serif; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline;">Conclusion</div><p class="chapter-para" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; font-size: 15px; line-height: 1.7em; font-family: inherit; font-optical-sizing: inherit; font-size-adjust: inherit; font-kerning: inherit; font-feature-settings: inherit; font-variation-settings: inherit; vertical-align: baseline;">One-half of highly symptomatic OH patients had mixed OH, whereas one-quarter had either pure neurogenic or non-neurogenic OH, respectively. Different forms of OH were indifferentiable based on haemodynamic responses during TTT, questioning the clinical utility of such classification. Larger studies are needed to confirm these findings.</p></div>}},
  author       = {{Johansson, Madeleine and Gagaouzova, Boriana S and van Rossum, Ineke A and Thijs, Roland D and Hamrefors, Viktor and van Dijk, J Gert and Fedorowski, Artur}},
  issn         = {{1532-2092}},
  keywords     = {{orthostatic hypotension}},
  language     = {{eng}},
  publisher    = {{Oxford University Press}},
  series       = {{Europace}},
  title        = {{Aetiology and haemodynamic patterns of orthostatic hypotension in a tertiary syncope unit}},
  url          = {{http://dx.doi.org/10.1093/europace/euaf017}},
  doi          = {{10.1093/europace/euaf017}},
  year         = {{2025}},
}