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Review
. 2016 Sep;29(9):1009-19.
doi: 10.1093/ajh/hpw023. Epub 2016 Apr 1.

Orthostatic Circulatory Disorders: From Nosology to Nuts and Bolts

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Review

Orthostatic Circulatory Disorders: From Nosology to Nuts and Bolts

Michael Gutkin et al. Am J Hypertens. 2016 Sep.

Abstract

When patients complain of altered consciousness or discomfort in the upright posture, either relieved by recumbency or culminating in syncope, physicians may find themselves baffled. There is a wide variety of disorders that cause abnormal regulation of blood pressure and pulse rate in the upright posture. The aim of this focused review is 3-fold. First, to offer a classification (nosology) of these disorders; second, to illuminate the mechanisms that underlie them; and third, to assist the physician in the practical aspects of diagnosis of adult orthostatic hypotension, by extending clinical skills with readily available office technology.

Keywords: baroreceptor testing; blood pressure measurement; hypertension; immune autonomic insufficiency; neurogenic orthostatic hypotension; orthostatic..

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Figures

Figure 1.
Figure 1.
The 4 phases of the Valsalva maneuver. The start of phase 3 is denoted by the black arrows. Phase 2 occupies the rectangles underneath Roman numeral II. In the control, the nadir is at a systolic blood pressure (BP) of about 20mm Hg below baseline. The time it takes for the BP to recover to baseline (the “pressure recovery time”) is short. In the subject with orthostatic hypotension (OH), the nadir is 60mm Hg below baseline, and the pressure recovery time is markedly prolonged. If this were a patient with the hyperadrenergic form of OH, or with orthostatic intolerance, the nadir would be intermediate between the normal and the neurogenic OH pattern. Close inspection shows that the longest beat-to-beat interval in phase 4 (overshoot) is greater than the shortest beat-to-beat interval in phase 2. The relationship between them describes the “valsalva ratio,” an index of parasympathetic activity. Reprinted by permission from Goldstein, DS, Sharabi, Y. Neurogenic orthostatic hypotension: a pathophysiologic approach. Circulation 2009;119:139-146, copyright American Heart Association.
Figure 2.
Figure 2.
A suggested approach to the patient with orthostatic circulatory disorders. Abbreviations: ABPM, ambulatory blood pressure monitoring; BP, blood pressure; ECHO, echocardiography; EOM, electronic oscillometric monitors; OI, orthostatic intolerance; OH, orthostatic hypotension; POTS, postural orthostatic tachycardia syndrome; VM, Valsalva maneuver analysis.

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