Current trends in evaluating and diagnosing syncope due to orthostatic hypotension: A case report

Abstract

IntroductionCardiac electrophysiology physicians frequently receive referrals to evaluate patients with syncope with requests for tilt table testing (TTT). This case report describes a patient with orthostatic hypotension (OH) that resulted in multiple syncope episodes and a referral to the electrophysiology service for evaluation and management, including a request for TTT.Case reportThe patient is a 71-year-old woman with a past medical history of syncope, orthostatic hypotension, diabetes mellitus type 2, dysautonomia, neuropathy, coronary artery disease, hypertension, morbid obesity, chronic pain, and multiple other comorbidities. The patient reported 4–5 episodes of syncope over the past year, with 3 occurring in the past 2 months while standing and attempting to get out of bed. As part of the initial cardiac workup, a 12-lead electrocardiogram revealed a normal sinus rhythm with left anterior fascicular block and nonspecific T-wave changes, while a transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 55%–60% with mild concentric left ventricular hypertrophy and impaired diastolic dysfunction. Serial orthostatic blood pressures (BP) while lying, sitting, and standing were taken at the bedside and found to be positive for reproducible orthostasis: (1) supine 124/56 to sitting 60/42, (2) supine 117/76 to sitting 66/45, (3) sitting 122/72 to standing 97/51. Neurology was consulted for further evaluation of autonomic dysfunction. The patient required aggressive pharmacotherapy including midodrine 10 mg 3 times per day, fludrocortisone 0.2 mg daily, and pyridostigmine. Droxidopa was also initiated but was discontinued owing to patient intolerance. Orders for compression stockings, increased fluid intake, head-of-bed elevation to 30 degrees, and physical therapy were placed.DiscussionOrthostatic hypotension (OH) is defined as a sustained reduction of systolic BP of 20 mm Hg or diastolic BP of 10 mm Hg within 3 minutes of assuming an upright posture.1Freeman R. Wieling W. Axelrod F.B. et al.Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.Clin Auton Res. 2011; 21: 69-72Crossref PubMed Scopus (956) Google Scholar It can be potentially debilitating and is caused by a dysfunction of the autonomic nervous system. Dysautonomia can be caused by multiple diseases, such as Parkinson’s disease or multisystem atrophy, which leads to abnormal signal output or processing from the peripheral nervous system, brain, or organs.2Kim M.J. Farrell J. Orthostatic hypotension: a practical approach.Am Fam Physician. 2022; 105: 39-49PubMed Google Scholar A thorough history and physical exam should aim to identify the prognosis, diagnosis, comorbidities, medication use, and reversible or ameliorable factors. Aggravating factors, such as side effects of medications, should be reviewed and adjusted accordingly. A neurology referral should also be made for an autonomic evaluation. During the initial evaluation of patients with syncope, a resting 12-lead electrocardiogram (ECG) should be performed (Class I recommendation), as these tests are widely available and can provide information concerning potential and specific arrhythmias that may cause syncope episodes. Additionally, cardiac imaging in the form of transthoracic echocardiogram can be useful in selected patients presenting with syncope if structural heart disease is suspected (class IIb recommendation).3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar Diagnosis of OH is determined by observation of supine and orthostatic BP at the bedside. If the diagnosis is unclear after initial evaluation, TTT can be useful for patients with suspected vasovagal syncope (class IIa recommendation).3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar In this case report, positive bedside OH observations provided the diagnosis and etiology of syncope, negating the need for further testing in the form of a TTT. Furthermore, the overall moderate sensitivity, specificity, reproducibility, presence of false-positive responses in controls, and availability of long-term cardiac monitoring have reduced the role of TTT in the evaluation of syncope.3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar In summary, this case report highlights current guidelines for the evaluation and diagnosis of syncope due to orthostatic hypotension. IntroductionCardiac electrophysiology physicians frequently receive referrals to evaluate patients with syncope with requests for tilt table testing (TTT). This case report describes a patient with orthostatic hypotension (OH) that resulted in multiple syncope episodes and a referral to the electrophysiology service for evaluation and management, including a request for TTT. Cardiac electrophysiology physicians frequently receive referrals to evaluate patients with syncope with requests for tilt table testing (TTT). This case report describes a patient with orthostatic hypotension (OH) that resulted in multiple syncope episodes and a referral to the electrophysiology service for evaluation and management, including a request for TTT. Case reportThe patient is a 71-year-old woman with a past medical history of syncope, orthostatic hypotension, diabetes mellitus type 2, dysautonomia, neuropathy, coronary artery disease, hypertension, morbid obesity, chronic pain, and multiple other comorbidities. The patient reported 4–5 episodes of syncope over the past year, with 3 occurring in the past 2 months while standing and attempting to get out of bed. As part of the initial cardiac workup, a 12-lead electrocardiogram revealed a normal sinus rhythm with left anterior fascicular block and nonspecific T-wave changes, while a transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 55%–60% with mild concentric left ventricular hypertrophy and impaired diastolic dysfunction. Serial orthostatic blood pressures (BP) while lying, sitting, and standing were taken at the bedside and found to be positive for reproducible orthostasis: (1) supine 124/56 to sitting 60/42, (2) supine 117/76 to sitting 66/45, (3) sitting 122/72 to standing 97/51. Neurology was consulted for further evaluation of autonomic dysfunction. The patient required aggressive pharmacotherapy including midodrine 10 mg 3 times per day, fludrocortisone 0.2 mg daily, and pyridostigmine. Droxidopa was also initiated but was discontinued owing to patient intolerance. Orders for compression stockings, increased fluid intake, head-of-bed elevation to 30 degrees, and physical therapy were placed. The patient is a 71-year-old woman with a past medical history of syncope, orthostatic hypotension, diabetes mellitus type 2, dysautonomia, neuropathy, coronary artery disease, hypertension, morbid obesity, chronic pain, and multiple other comorbidities. The patient reported 4–5 episodes of syncope over the past year, with 3 occurring in the past 2 months while standing and attempting to get out of bed. As part of the initial cardiac workup, a 12-lead electrocardiogram revealed a normal sinus rhythm with left anterior fascicular block and nonspecific T-wave changes, while a transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 55%–60% with mild concentric left ventricular hypertrophy and impaired diastolic dysfunction. Serial orthostatic blood pressures (BP) while lying, sitting, and standing were taken at the bedside and found to be positive for reproducible orthostasis: (1) supine 124/56 to sitting 60/42, (2) supine 117/76 to sitting 66/45, (3) sitting 122/72 to standing 97/51. Neurology was consulted for further evaluation of autonomic dysfunction. The patient required aggressive pharmacotherapy including midodrine 10 mg 3 times per day, fludrocortisone 0.2 mg daily, and pyridostigmine. Droxidopa was also initiated but was discontinued owing to patient intolerance. Orders for compression stockings, increased fluid intake, head-of-bed elevation to 30 degrees, and physical therapy were placed. DiscussionOrthostatic hypotension (OH) is defined as a sustained reduction of systolic BP of 20 mm Hg or diastolic BP of 10 mm Hg within 3 minutes of assuming an upright posture.1Freeman R. Wieling W. Axelrod F.B. et al.Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.Clin Auton Res. 2011; 21: 69-72Crossref PubMed Scopus (956) Google Scholar It can be potentially debilitating and is caused by a dysfunction of the autonomic nervous system. Dysautonomia can be caused by multiple diseases, such as Parkinson’s disease or multisystem atrophy, which leads to abnormal signal output or processing from the peripheral nervous system, brain, or organs.2Kim M.J. Farrell J. Orthostatic hypotension: a practical approach.Am Fam Physician. 2022; 105: 39-49PubMed Google Scholar A thorough history and physical exam should aim to identify the prognosis, diagnosis, comorbidities, medication use, and reversible or ameliorable factors. Aggravating factors, such as side effects of medications, should be reviewed and adjusted accordingly. A neurology referral should also be made for an autonomic evaluation. During the initial evaluation of patients with syncope, a resting 12-lead electrocardiogram (ECG) should be performed (Class I recommendation), as these tests are widely available and can provide information concerning potential and specific arrhythmias that may cause syncope episodes. Additionally, cardiac imaging in the form of transthoracic echocardiogram can be useful in selected patients presenting with syncope if structural heart disease is suspected (class IIb recommendation).3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar Diagnosis of OH is determined by observation of supine and orthostatic BP at the bedside. If the diagnosis is unclear after initial evaluation, TTT can be useful for patients with suspected vasovagal syncope (class IIa recommendation).3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar In this case report, positive bedside OH observations provided the diagnosis and etiology of syncope, negating the need for further testing in the form of a TTT. Furthermore, the overall moderate sensitivity, specificity, reproducibility, presence of false-positive responses in controls, and availability of long-term cardiac monitoring have reduced the role of TTT in the evaluation of syncope.3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar In summary, this case report highlights current guidelines for the evaluation and diagnosis of syncope due to orthostatic hypotension. Orthostatic hypotension (OH) is defined as a sustained reduction of systolic BP of 20 mm Hg or diastolic BP of 10 mm Hg within 3 minutes of assuming an upright posture.1Freeman R. Wieling W. Axelrod F.B. et al.Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.Clin Auton Res. 2011; 21: 69-72Crossref PubMed Scopus (956) Google Scholar It can be potentially debilitating and is caused by a dysfunction of the autonomic nervous system. Dysautonomia can be caused by multiple diseases, such as Parkinson’s disease or multisystem atrophy, which leads to abnormal signal output or processing from the peripheral nervous system, brain, or organs.2Kim M.J. Farrell J. Orthostatic hypotension: a practical approach.Am Fam Physician. 2022; 105: 39-49PubMed Google Scholar A thorough history and physical exam should aim to identify the prognosis, diagnosis, comorbidities, medication use, and reversible or ameliorable factors. Aggravating factors, such as side effects of medications, should be reviewed and adjusted accordingly. A neurology referral should also be made for an autonomic evaluation. During the initial evaluation of patients with syncope, a resting 12-lead electrocardiogram (ECG) should be performed (Class I recommendation), as these tests are widely available and can provide information concerning potential and specific arrhythmias that may cause syncope episodes. Additionally, cardiac imaging in the form of transthoracic echocardiogram can be useful in selected patients presenting with syncope if structural heart disease is suspected (class IIb recommendation).3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar Diagnosis of OH is determined by observation of supine and orthostatic BP at the bedside. If the diagnosis is unclear after initial evaluation, TTT can be useful for patients with suspected vasovagal syncope (class IIa recommendation).3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar In this case report, positive bedside OH observations provided the diagnosis and etiology of syncope, negating the need for further testing in the form of a TTT. Furthermore, the overall moderate sensitivity, specificity, reproducibility, presence of false-positive responses in controls, and availability of long-term cardiac monitoring have reduced the role of TTT in the evaluation of syncope.3Shen W. Sheldon R. Benditt D. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (149) Google Scholar In summary, this case report highlights current guidelines for the evaluation and diagnosis of syncope due to orthostatic hypotension.