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Orthostatic Intolerance and Orthostatic Hypotension

Journal Articles

Orthostatic Intolerance (OI) is a general term that refers to the body not responding correctly to being upright, and symptoms are relieved by lying down (called recumbence). The body naturally compensates for being upright by constricting blood vessels, producing a mild increase in heart rate (usually under 10-15 beats per minute), and sometimes causing a slight increase in blood pressure.  This keeps blood flowing to the brain, lungs, and other organs, and circulating oxygen normally.  In people with Orthostatic Intolerance and Orthostatic Hypotension, these compensations for gravity when standing do not happen properly, sometimes causing the body to work harder to maintain blood pressure, and get enough oxygen and blood to the brain.   

Many healthy people experience being dizzy when they stand up too fast at some point in their life, as it actually is very common, especially in the elderly. Things like dehydration, the flu, and other temporary illnesses can cause OI, and are termed "acute".  But when it happens frequently over a longer period of time, even day to day, it may be a chronic condition, and can either be primary or secondary to another disease. Finding out why it is happening is important.

 

 

The most common chronic Orthostatic Intolerance conditions that involve dysautonomia currently include Postural Tachycardia Syndrome (POTS) and Neurally Mediated Syncope (NMS), formerly known as Neurocardiogenic Syncope (NCS). Some physicians will use Orthostatic Intolerance as a diagnosis itself if a patient doesn't meet the diagnostic requirements for the other OI conditions, but still suffers from symptoms when upright. The definitions change frequently among physicians and researchers, so it is a very confusing topic.​ OI is also often mistaken for anxiety, as it sometimes mimics many symptoms of a panic attack, and occurs mainly in younger women. OI is also very closely associated with Chronic Fatigue Syndrome (CFS) and Fibromyalgia, and there currently is research taking place as to the exact relationship and the mechanisms behind that relationship.

Orthostatic Hypotension is a type of Orthostatic Intolerance as well, and is defined by the American Autonomic Society as being a persistent fall in systolic/diastolic BP of more than 20/10 mm Hg within 3 minutes of assuming the upright position or during a Tilt Table Test. It is a "clinical sign" and not a disease unto itself. It can be found in people with Multiple Systems Atrophy, Pure Autonomic Failure, and secondary conditions that cause dysautonomia, such as Guillain-Barré syndrome, Diabetes, Parkinson's, and autonomic neuropathy (to name a few). Symptoms are typically worse in the early morning, with prolonged standing, after meals, with a rise in core temperature, and with activity.

According to the 2011 Autonomic Society Consensus Statement, Orthostatic Hypotension is caused by an excessive fall of cardiac output or by defective or inadequate vasoconstrictor mechanisms. That means that blood vessels are not constricting (squeezing) as they should, and blood is pooling in the extremities and abdomen, causing a drop in blood pressure. Neurogenic Orthostatic Hypotension (NOH) is Orthostatic Hypotension due to inadequate release of norepinephrine from sympathetic vasomotor neurons leading to vasoconstrictor failure. This means that the blood vessels are not squeezing the blood vessels to keep it circulating properly because of a lack of the release of norepinepherine, which is a type of adrenalin.   

Symptoms Include (some are relieved by lying down):

 

Find information on the most common forms of chronic Orthostatic Intolerance below, including an excellent video by Dr. Peter Rowe from Johns Hopkins on managing Orthostatic Intolerance:
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Sources:
1. Orthostatic Intolerance. Julian M Stewart, MD, PhD, Marvin S Medow, PhD, written for Medscape Reference Online.
2. Mechanisms of Sympathetic Regulation in Orthostatic Intolerance. Julian M Stewart, J Appl Physiol. 2012 Jun 7. [Epub ahead of print].
3. Orthostatic intolerance and the headache patient. Mack KJ, Johnson JN, Rowe PC, Semin Pediatr Neurol. 2010 Jun;17(2):109-16.
4. Predictors of orthostatic intolerance in healthy young women. Cote AT, Bredin SS, Phillips AA, Warburton DE., Clin Invest Med. 2012 Apr 1;35(2):E65-74.
5. Increasing orthostatic stress impairs neurocognitive functioning in chronic fatigue syndrome with postural tachycardia syndrome. Ocon AJ, Messer ZR, Medow MS, Stewart JM., Clin Sci (Lond). 2012 Mar;122(5):227-38.
6. Correlations between autonomic dysfunction and circadian changes and arrhythmia prevalence in women with fibromyalgia syndrome. Doğru MT, Aydin G, Tosun A, Keleş I, Güneri M, Arslan A, Ebinç H, Orkun S., Anadolu Kardiyol Derg. 2009 Apr;9(2):110-7.
7. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Freeman R et al. , Auton Neurosci. 2011 Apr 26;161(1-2):46-8. Epub 2011 Mar 9.​
​8.  Mortality and prognosis in patients with neurogenic orthostatic hypotension. Maule S, Milazzo V, Maule MM, Di Stefano C, Milan A, Veglio F.,Funct Neurol. 2012 Apr-Jun;27(2):101-6.​​​​​
9.  Management of neurogenic orthostatic hypotension: an update. ​Low PA, Singer W., ​Lancet Neurol. 2008 May;7(5):451-8.
10. Orthostatic hypotension. A primary care primer for assessment and treatment. Sclater A, Alagiakrishnan K., Geriatrics. 2004 Aug;59(8):22-7.
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Originally written by Claire Martin, President of Dysautonomia SOS