Caveats: Could A Healthy Population Skew The Results
The population in this study was relatively healthy, with a lower prevalence of diabetes and coronary artery disease than the general population. While there is no reason to expect detection of OH to differ in a population with more comorbidities, the possibility exists.
If OH is not identified in < 1 minute of standing, standard OH evaluation within 3 minutes after standing should be performed, as OH identified at any time point after standing is associated with adverse events and increased mortality.
This study did not address the effects of medical intervention for OH on injury or mortality. Also, whether OH is the direct cause of the adverse outcomes or a marker for other disease is unknown.
Duration Matters Less Is Not More
Time matters this study validated the results of another tilt table study which indicated that the 1-3 minute orthostatic assessment typically carried out in doctors offices isnt enough. Even a 2-5 minute tilt table test will miss a considerable set of POTS patients.
The Lee-Bateman study found that at least 5 minutes of the NASA lean test are necessary to pick up signs of orthostatic intolerance in most of the participants and a full ten minutes are needed to pick up more.
What Makes Orthostatic Readings Different
Many people have a tendency to take someones blood pressure when they are sitting down and they have been doing so for at least a few minutes. There is certainly nothing wrong with this procedure. In fact, that is the procedure that most individuals follow. However, when a patient comes in with signs and symptoms that indicate that they could potentially have a condition related to orthostatic blood pressure issues, it is important to test that theory by taking their vitals while they are doing something beside merely sitting down. This is essentially the only way to determine whether or not their problems are being caused by a sudden drop in blood pressure or in some cases, a rapid increase in both and blood pressure that is involved with a very specific form of hypertension.
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Lifestyle And Home Remedies
If youre experiencing dizziness or fainting spells often, its important to check in with a doctor as soon as possible to rule out a more serious issue.
Once they diagnose your condition, your doctor may recommend some lifestyle changes that may help lessen your symptoms, including:
- increasing your fluid and water intake and limiting your alcohol intake if youre dehydrated
- performing isometric exercises before getting up to help raise your blood pressure
- avoiding hot baths or long walks in hot weather
- standing up slowly
- wearing compression stockings to help with circulation in your legs
- adding salt to your daily meals to help you retain fluid
For severe cases, your doctor may prescribe drugs that work to increase blood volume or constrict blood vessels. These drugs might include:
Evaluation And Management Of Orthostatic Hypotension
JEFFREY B. LANIER, MD MATTHEW B. MOTE, DO and EMILY C. CLAY, MD, Martin Army Community Hospital Family Medicine Residency, Fort Benning, Georgia
Am Fam Physician. 2011 Sep 1 84:527-536.
Patient information: See related handout on orthostatic hypotension, written by the authors of this article.
Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing compared with blood pressure from the sitting or supine position. Alternatively, the diagnosis can be made by head-up tilt-table testing at an angle of at least 60 degrees.1 Orthostatic hypotension is often found in older patients and in those who are frail.2 It is present in up to 20 percent of patients older than 65 years.3 In one study, the prevalence of orthostatic hypotension was 18 percent in patients older than 65 years, but only 2 percent of these patients were symptomatic.3
In the absence of volume depletion, younger patients with orthostatic hypotension usually have chronic autonomic failure. A related problem, postprandial hypotension, is common in older patients and those with autonomic dysfunction. In postprandial hypotension, there is a decrease in systolic blood pressure of at least 20 mm Hg within 75 minutes of a meal.4
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Orthostatic Blood Pressure & Adrenal Function
The orthostatic blood pressure test measures the supine blood pressure and then the standing blood pressure. The test is an indicator of how efficiently blood is pumped to the upper extremities. If cardiac output is weak, this will often result in orthostatic hypofunction: a decrease in systolic blood pressure upon standing. Conversely, if cardiac output is excessive, this will tend to result in orthostatic hypertension: an excessive increase in systolic blood pressure.
The implications for the orthostatic blood pressure tests are many. First of all, the orthostatic tests are reflective of several possible imbalances in the body.
- Autonomic nervous system stress. Orthostatic hyperfunction indicates excess sypathetic nervous system function and possible vasoconstriction. Orthostatic hypofunction indicates excess parasympathetic nervous system function and possible excess vasodilation.
- Electrolyte imbalance. In hypofunction, deficiencies of certain minerals like sodium can result in diminished cardiac output. In hyperfunction, a deficiency of potassium and magnesium may result in vasoconstriction.
- Adrenal Excess often found in a similar pattern with orthostatic hyperfunction.
- Adrenal Insufficiency often found with orthostatic hypofunction.
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What You Need To Know
- POTS is a common condition affecting an estimated one to three million Americans.
- The symptoms of POTS include but are not limited to lightheadedness , difficulty thinking and concentrating , fatigue, intolerance of exercise, headache, blurry vision, palpitations, tremor and nausea.
- Researchers dont fully understand the causes of POTS, but it is more common in women than men and is more likely to develop in adolescents and young adults.
- POTS is diagnosed using either a 10-minute standing test or a head-up tilt table test occasionally other tests are performed to identify specific characteristics of POTS present in some patients.
- Most peoples POTS symptoms respond to a combination of diet, medications, physical therapy and other treatments.
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Tilt Table Test For Pots
During the tilt table test, you are secured on a table while lying flat. Then the table is raised to an almost upright position. Your heart rate, blood pressure and often blood oxygen and exhaled carbon dioxide levels are measured during this test.
You might have POTS if you meet all three of these criteria:
Your body produces an abnormal heart rate response to being upright
Your symptoms worsen when upright
You dont develop orthostatic hypotension in the first three minutes of testing
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How To Evaluate The Findings
Normal variation is a 10 mm Hg decrease in blood pressure from lying to standing and an increase in pulse of 1015 bpm.
A decrease in blood pressure from lying to standing of systolic 20 mm Hg or diastolic 10 mm Hg is identified as orthostatic hypotension.
An increase in pulse from lying to standing of 20 bpm is identified as orthostatic pulse.
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How Is Orthostatic Hypotension Diagnosed
Your healthcare provider will check your blood pressure while youre seated, lying down and standing. You may also get one or more of these tests:
- Blood tests to check for conditions like diabetes and anemia.
- Echocardiogram to check the hearts pumping action.
- Electrocardiogram to test for heart rhythm changes.
- Exercise stress test to measure heart rate during physical exertion.
- Portable EKG devices to measure heart rhythm.
- Tilt table test to safely measure blood pressure, heart rate and heart rhythm while you lie on a table that moves from horizontal to vertical.
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Exercise For Postural Orthostatic Tachycardia Syndrome
Physical therapy can make a difference for some people with POTS. Because sometimes POTS symptoms can worsen with exercise, physical therapy has to start slowly and advance based on your tolerance rather than a rigid plan. As your blood circulation improves with medications and diet, the exercise intensity may be gradually increased. The goal is to retrain the autonomic nervous system to allow for more exercise, which then helps increase the blood volume.
Those who cant stand upright may start exercising in a horizontal or reclined position. Aquatic therapy may work for some POTS patients due to the water creating pressure around the body. Many experts find that manual physical therapy that addresses issues with nerve tightness and range of motion works as a bridge to build better tolerance of exercise.
What Questions Should I Ask My Doctor
You may want to ask your healthcare provider:
- Why did I get orthostatic hypotension?
- What is the best treatment for orthostatic hypotension?
- Could medications be causing my symptoms? Should I change medications?
- What changes should I make to manage symptoms?
- Should I look out for signs of complications?
A note from Cleveland Clinic
Orthostatic hypotension symptoms can be unsettling. They may even be dangerous if you lose your balance, fall or pass out. Symptoms often improve when you change how you move into a standing position. Tell your healthcare provider about your symptoms. You may need to change your medications to reduce or prevent symptoms. In more severe cases, your provider may prescribe medicine to improve blood flow and pressure.
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Adding Sodium To Your Diet
One reason that people with POTS feel lightheaded upon standing is insufficient circulating blood volume. Drinking more fluids will help, but the key to keeping the fluids in circulation is sodium.
For reasons not fully understood, many people who have POTS need up to three times more sodium than the standard limit recommended by the US Dietary Guidelines, which is 2,300 milligrams a day . Some of my patients can consume this much sodium by eating salty foods such as tomato juice, broth, pickles, and olives. Others prefer to use high-sodium electrolyte drinks or take salt tablets.
David opted to start with a glass of tomato juice every morning and a 1-gram salt tablet with lunch, in addition to adding salt to his meals. Even though David could easily meet his sodium needs by eating highly processed junk foods, I recommended he avoid these because of their low nutrient value.
Prognosis Depends On Cause
Orthostatic hypotension is a syndrome, and its prognosis depends on its specific cause, its severity, and the distribution of its autonomic and nonautonomic involvement. In patients who have extrapyramidal and cerebellar disorders , the earlier and the more severe the involvement of the autonomic nervous system, the poorer the prognosis.9,10
In hypertensive patients with diabetes mellitus, the risk of death is higher if they have orthostatic hypotension.11 Diastolic orthostatic hypotension is associated with a higher risk of vascular death in older persons.12
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Types And Causes Of Pots
The causes of POTS vary from person to person. Researchers dont entirely understand the origins of this disorder. The classification of POTS is the subject of discussion, but most authorities recognize different characteristics in POTS, which occur in some patients more than others. Importantly, these characteristics are not mutually exclusive person with POTS may experience more than of these at the same time:
Neuropathic POTS is a term used to describe POTS associated with damage to the small fiber nerves . These nerves regulate the constriction of the blood vessels in the limbs and abdomen.
Hyperadrenergic POTS is a term used to describe POTS associated with elevated levels of the stress hormone norepinephrine.
Hypovolemic POTS is a term used to describe POTS associated with abnormally low levels of blood .
Secondary POTS means that POTS is associated with another condition known to potentially cause autonomic neuropathy, such as diabetes, Lyme disease, or autoimmune disorders such as lupus or Sjögrens syndrome.
Postural Orthostatic Tachycardia Syndrome
Postural orthostatic tachycardia syndrome is a blood circulation disorder characterized by two factors:
A specific group of symptoms that frequently occur when standing upright
A heart rate increase from horizontal to standing of at least 30 beats per minute in adults, or at least 40 beats per minute in adolescents, measured during the first 10 minutes of standing
POTS is diagnosed only when orthostatic hypotension is ruled out and when there is no acute dehydration or blood loss. Orthostatic hypotension is a form of low blood pressure: 20mm Hg drop in systolic or a 10mm Hg drop in diastolic blood pressure in the first three minutes of standing upright.
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Postural Orthostatic Tachycardia Syndrome Diet
The foundation of treating POTS is to drink fluids frequently throughout the day. For most POTS patients, the goal is at least 64-80 ounces a day. You would also need to increase your intake of salty foods and add more salt to your diet with a saltshaker or salt tablets. These dietary modifications help keep water in the bloodstream, which helps more blood reach the heart and the brain.
Certain foods or drinks can have an adverse effect on POTS symptoms in some patients. For example, alcohol almost always aggravates POTS. It diverts blood away from the central circulation to the skin and increases loss of fluids through urine. Caffeine can make some people more nervous and lightheaded, but for some it can help improve constriction of blood vessels. Your regular physician or POTS specialist can help you determine how your diet and certain medications could be helping or hindering your treatment.
Where Can I Get My Blood Pressure Checked
You can get your blood pressure measured
- By a health care team member at a doctors office.
- At a pharmacy that has a digital blood pressure measurement machine.
- With a home blood pressure monitor that you can use yourself.
Take this form pdf icon with you on your first blood pressure visit to record important blood pressure-related information.
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Orthostatic Hypertension In Children: An Update
- 1Department of Pediatrics, Peking University First Hospital, Beijing, China
- 2Research Unit of Clinical Diagnosis and Treatment of Pediatric Syncope and Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
- 3Key Laboratory of Cardiovascular Sciences, Ministry of Education, Beijing, China
The concept of orthostatic hypertension in children was first proposed in 2012. The pathogenesis is not clear by now. Orthostatic hypertension is one of the important causes of orthostatic intolerance in children and is related to the development of essential hypertension in the future. It is commonly seen in older children, with dizziness and syncope as their main clinical manifestations. Non-drug therapy is the commonly used treatment strategy, which is effective to improve the orthostatic intolerance symptoms. In this paper, we reviewed the clinical studies on the pathogenesis, clinical characteristics, diagnostic criteria, and treatment of orthostatic hypertension in children, aiming to provide new insights for the future studies on pediatric orthostatic hypertension.
How Is Pots Diagnosed
Measuring blood pressure and heart rate while lying down, then while standing can help cardiologists like me diagnose POTS. Within 10 minutes of standing, the heart rate rises at least 30 beats per minute in POTS and, importantly, the blood pressure remains stable .
These findings, along with symptoms of orthostatic intolerance , must be present for at least three to six months for a person to be diagnosed with POTS. Because many doctors are not familiar with POTS, and since there is no laboratory test to confirm it, people often experience symptoms for several years before being diagnosed.
Accordingly, when David, a firefighter, came to my office, we measured his heart rate and blood pressure lying down and then standing upright. While lying flat, his heart rate and blood pressure were normal, and he felt fine. However, after standing upright for just three minutes, he began to feel lightheaded. His heart rate increased by 35 bpm with no significant drop in blood pressure. David had POTS.
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