Syndromes of orthostatic intolerance: a hidden danger
Abstract
Orthostatic hypotension (OH) is a relatively common heterogenous and multifactorial disorder, traditionally classified as neurogenic (less common but often more severe) or nonneurogenic (more common, with no direct signs of autonomic nervous system disease). The different clinical variants of orthostatic intolerance include initial, classical and delayed OH as well as postural tachycardia syndrome. Orthostatic instability may induce syncopal attacks either alone or in combination with other mechanisms, and is often dismissed as a precipitating factor. Moreover, prevalent OH is an independent risk factor for all-cause mortality and cardiovascular morbidity, and the majority of patients with OH are asymptomatic or have few nonspecific symptoms. Management of symptomatic orthostatic intolerance includes both nonpharmacological and pharmacological methods, but it is not always successful and may lead to complications. Future studies of OH should focus on mechanisms that lead to neurogenic and nonneurogenic OH, novel diagnostic methods and more effective therapeutic modalities.
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POTS-related syncope differs from classic vasovagal syncope.
“POTS-related syncope differs from classic vasovagal syncope (VVS), as the underlying symptoms are present constantly with occasional syncope associated with a preceding tachycardia and associated adrenergic symptoms. In contrast, VVS typically features episodic syncope and asymptomatic periods between attacks.1,4,7”
From Antiadrenergic autoimmunity in postural tachycardia syndrome (2017) · cites this paper as [7]
Treatment options for POTS have limited efficacy in the more severe forms and are often questioned.
“A number of treatment options have been proposed in POTS but their efficacy in the more severe forms is limited and often questioned.2,7”
From Antiadrenergic autoimmunity in postural tachycardia syndrome (2017) · cites this paper as [7]
Droxidopa is a peroral norepinephrine precursor.
“Peroral norepinephrine precursor.”
From Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management (2019) · cites this paper as [77]
Midodrine is a direct alpha1-adrenoreceptor agonist.
“Direct a1-adrenoreceptor agonist.”
From Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management (2019) · cites this paper as [77]
Midodrine may be effective in POTS patients with the hypovolaemic subtype and a low-blood-pressure phenotype with pronounced orthostatic intolerance.
“It may be effective in 'hypovolaemic' subtype and low-BP phenotype with pronounced orthostatic intolerance.”
From Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management (2019) · cites this paper as [77]
Droxidopa has been used off-label empirically in severe POTS.
“Drug has been empirically used offlabel in severe POTS.”
From Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management (2019) · cites this paper as [77]
Midodrine is one of the few pharmacological agents positively tested in placebo-controlled studies for orthostatic hypotension.
“One of the few pharmacological agents positively tested in placebo-controlled studies for orthostatic hypotension.”
From Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management (2019) · cites this paper as [77]
Ephedrine and pseudoephedrine are direct and indirect alpha1-adrenoreceptor agonists.
“Direct and indirect a1-adrenoreceptor agonist.”
From Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management (2019) · cites this paper as [77]
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References 126 · Cited by 151
- Authors
- Fedorowski, A., & Melander, O.
- Affiliations
- Lund University (SE)
- Corresponding author
- Fedorowski, A.
- Venue
- Journal of Internal Medicine
- Publisher
- Wiley
- Published
- 2013-03-20
- Volume
- 273
- Issue
- 4
- Pages
- 322-335
- ISSN
- 0954-6820 (ISSN-L)
- 1365-2796
- OpenAlex
- W1995830421
- Cited by
- 151
- References
- 126
- Citations by year
- 2026: 8 · 2025: 12 · 2024: 10 · 2023: 6 · 2022: 6 · 2021: 9 · 2020: 18 · 2019: 13 · 2018: 15 · 2017: 16 · 2016: 13 · 2015: 12 · 2014: 7 · 2013: 5
- FWCI
- 2.18
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Lund University Publications (Lund University) (submittedVersion)
- 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 › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Balance, Gait, and Falls Prevention
- Keywords
- orthostatic intolerance, orthostatic hypotension, neurogenic orthostatic hypotension, postural orthostatic tachycardia syndrome, syncope, cardiovascular mortality, autonomic nervous system
- MeSH terms
- Humans, Posture, Risk Factors, Syncope, Syndrome, Global Health, Prevalence, Orthostatic Intolerance
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