NEW YORK (Reuters Health) – Over half of patients with profound orthostatic hypotension do not have typical symptoms, according to a new report. Therefore it may be necessary to perform head-up tilt table tests in all patients who fall or have suspected syncope.

Dr. Steven D. Arbogast at University Hospitals Case Medical Center in Cleveland, Ohio and colleagues note in the June issue of the American Journal of Medicine that physicians usually depend on patients to self-report symptoms of orthostatic hypotension. However, they point out, “Examination has already come under fire” as an unreliable means for detecting the problem, “as standard orthostatic vital signs will miss delayed orthostatic hypotension.”

Dr. Arbogast and his team studied the records of 205 patients who had systolic blood pressure decreases of 60 mm Hg or more during head-up tilt table testing at their center. These patients had been referred for testing for reasons that included not only orthostatic hypotension but also unexplained falls, syncope, dizziness, Parkinsonism, and autonomic neuropathy.

According to the report, 88 of the patients (43%) had typical symptoms of orthostatic hypotension, 49 (24%) had atypical symptoms, and 68 (33%) were asymptomatic. The researchers have termed the latter two conditions “hypotension unawareness.”

Mean falls in systolic pressure in the typical, atypical, and asymptomatic groups were 88 mm Hg, 87.5 mm Hg, and 89.8 mm Hg, respectively.

Atypical symptoms included lower extremity discomfort, backache, and headache, the authors found.

“The findings of this study are robust enough to suggest a change in medical practice,” the researchers advise, adding that “a reliance on history in ascertaining the presence of orthostatic hypotension may falsely lead away from the diagnosis.”

They conclude, “Because the bedside examination is also insensitive for the diagnosis of orthostatic hypotension, clinicians might have little recourse but to obtain head-up tilt table test in any patient who falls.”

Reference:
Am J Med 2009;122:574-580.