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Cited by 374Cardiovascular Syncope and Autonomic DisordersHeart Rate Variability and Autonomic ControlBlood Pressure and Hypertension Studies

Initial orthostatic hypotension: review of a forgotten condition

Wieling, Wouter, Krediet, C. T. Paul, van Dijk, Nynke, Linzer, Mark, Tschakovsky, Michael E.·2007·Clinical Science
DOI 10.1042/cs20060091
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Abstract

Several studies have shown that standing up is a frequent (3-10%) trigger of loss of consciousness both in young and old subjects. An exaggerated transient BP (blood pressure) fall upon standing is the underlying cause. IOH (initial orthostatic hypotension) is defined as a transient BP decrease within 15 s after standing, >40 mmHg SBP (systolic BP) and/or >20 mmHg DBP (diastolic BP) with symptoms of cerebral hypoperfusion. It differs distinctly from typical orthostatic hypotension (i.e. BP decrease >20 mmHg SBP and/or >10 mmHg DBP after 3 min of standing) as the BP decrease is transient. Only continuous beat-to-beat BP measurement during an active standing-up manoeuvre can document this condition. As IOH is only associated with active rising, passive tilting is of no diagnostic value. The pathophysiology of IOH is thought to be a temporal mismatch between cardiac output and vascular resistance. The marked decrease of vascular resistance during rising is similar to that observed at the onset of leg exercise and is absent during head-up tilting. It is attributed to vasodilatation in the working muscle through local mechanisms. Standing up causes an initial increase in venous return through the effects of contraction of leg and abdominal muscles. The consequent sudden increase in right atrial pressure may contribute to the fall in systemic vascular resistance through a reflex effect. This review alerts clinicians and clinician scientists to a common, yet often neglected, condition that occurs only upon an active change of posture and discusses its epidemiology, pathophysiology and management.

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  • Syncope due to OH is confirmed when syncope occurs while standing and there is concomitant significant OH.

    “Syncope due to OHis confirmed when syncope occurs while standing and there is concomitant significant OH. 18-24”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [22]

  • The heart rate increase in POTS must be sustained; a transient increase immediately on standing that improves after about 45 seconds is likely a variant of initial orthostatic hypotension and is not itself POTS.

    “First, the HR increase must be sustained.Many people will have a transient increase in HR immediately on standing that gets better after the first 45 s.This likely relates to a variant of initial orthostatic hypotension”

    From Postural tachycardia syndrome – Diagnosis, physiology, and prognosis (2018) · cites this paper as Wieling et al., 2007

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Authors
Wieling, W., Krediet, C. T. P., van Dijk, N., Linzer, M., & Tschakovsky, M. E.
Affiliations
  • Amsterdam UMC Location University of Amsterdam (NL)
  • Department of Internal Medicine, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
  • University of Wisconsin–Madison (US)
  • Queen's University (CA)
Corresponding author
Wieling, Wouter
ORCID
Venue
Clinical Science
Publisher
Portland Press Ltd.
Published
2007-01-03
Volume
112
Issue
3
Pages
157-165
ISSN
  • 0143-5221 (ISSN-L)
  • 1470-8736
DOI
10.1042/cs20060091
OpenAlex
W1997275331
Cited by
374
References
2
Citations by year
2026: 7 · 2025: 16 · 2024: 18 · 2023: 17 · 2022: 19 · 2021: 19 · 2020: 28 · 2019: 22 · 2018: 29 · 2017: 35 · 2016: 15 · 2015: 25 · 2014: 15 · 2013: 25 · 2012: 20
FWCI
2.98
Type
journal article
Language
en
Open access
closed
Locations
  • Clinical Science (publishedVersion)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Funders
Medtronic Europe
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
Keywords
orthostatic hypotension, loss of consciousness, cerebral hypoperfusion, venous return, right atrial pressure, head-up tilt, posture change, pathophysiology
MeSH terms
Cardiac Output, Humans, Hypotension, Orthostatic, Posture, Syncope, Vascular Resistance

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