The Orthostatic Intolerance (OI) Center
Medical Care for OI
Initial Evaluation of Dizziness, OI
• Preparing - 1st Visit
• Get a Diagnosis-1st Visit
• List of Possible Causes-OI
• 1st Visit Lab & Tests
The Initial Evaluation of Orthostatic Symptoms & Fainting
The first step to find out what is causing a person's orthostatic symptoms (like dizziness, weakness, fatigue, and exercise intolerance) when they stand up is the office visit with a physician.
The American Heart Association and other guidelines on syncope (fainting) consider the history, physical exam and EKG as the first steps to evaluating fainting and orthostatic symptoms.1,2,3
The History
A good history, getting the details about the fainting events and symptoms that come with standing is essential.
The Physical Exam - Including Blood Pressure and Pulse Testing
The physical exam would include an exam of the heart and the neurologic system. It should also include doing a blood pressure and pulse reading when the person is lying down and then when standing up. (See the Standing Test below for details.)
Initial Assessment of the Cause of the Fainting or Orthostatic Symptoms:
With the information from the history, the physical, the Standing BP test and the EKD, It is often possible to diagnosis the cause of the fainting or syncope in about 60% of the people1. This is especially true when the cause of the fainting is one of these conditions:
- Syncope or fainting: classical reflex syncope or fainting - vasovagal or situational syncope;
- Cardiac ischemia-related syncope and arrhythmia-related syncope.(Go to Fainting-Types and Cause for more details.)
- Neurogenic Orthostatic Hypotension (NMH) or OH
- If the BP/pulse test is done for 10 minutes, it is even possible to diagnose Postural Orthostatic Tachycardia Syndrome (POTS).
With this information, it is possible to develop a management plan.
When Additional Testing Is Needed
If the diagnosis cannot be made with the history, physical (including Standing BP/Pulse Test and EKG, it is recommended that further studies be done. Some recommend additional testing if the person has consistent orthostatic symptoms and the symptoms significantly interfere with their daily activities.7 They recommend further testing if the person scores a 3 or 4 by symptoms. Grading of Orthostatic Intolerance )
The first decision is whether there is evidence that there is a cardiac problem.
• If it is suspected that the heart is the cause: go to Evaluation - For Cardiac Cause
• If it is suspected that it is a nervous system or neural cause: If cardiac evaluation, including the EKG, does not show evidence of arrhythmia as a cause of syncope, evaluation for neurally-mediated syndromes is recommended if a diagnosis has not been already found.3 Go to Evaluation - For a Neurologic Cause
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This is the test that most matches what happens to a person in real life with standing up.4
How the test is done5: The area around the person when they stand up needs to be safe, in case they do faint and fall. Someone needs to be with the person during the whole time the test is being done. Emergency equipment should be available.
- The person should lie down for 2-5 minutes before their blood pressure and heart rate are measured while they are lying down.
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Then, the person stands up, leaning back against a wall with their feet positioned 2 to 6 inches
from the baseboard or against the exam table. It helps to remind them that should not move - no wiggling, no tightening muscles in legs, arms, hands. - Blood pressure, heart rate and symptoms are recorded each minute by using an automated blood pressure cuff, with the arm resting at the patient’s side. The shortest measure should be 10 minutes. It is not necessary (or possible) to do measures every minute. The critical times are 1, 2 or 3 minutes, 5 minutes and 10 minutes. Record all symptoms - dizziness, vision change, hearing change, pain, short of breath/fast breathing, stomach symptoms, tingling, twitching etc. Then, take a look at their skin (especially their hands/forearms) - touch it for temperature and clamminess and look at the legs and feet to see if they are pink/red, mottled or blue.5)
- For a full evaluation, the test should be continued for 45 minutes but this is not always practical in the office setting.
When to stop the test
— BP systolic (top number) is lower than 80 mmHg
— Pulse goes over 140
— if the person get pale and starts to sweat a really lot (profusely)
— If the person faints or feels ready to faint
— When the person asks to stop it
If they feel like they are going to faint or need to stop, have them
• squat down,
• sit on the floor with your legs crossed (like the meditation poses) or
• lie down flat, have them pull their knees up to their chest and hug their knees.
Be sure to write down how many minutes have gone by since they stood up when this happened and all the symptoms they are feeling. It may take a few minutes for things to settle down.
Also - sometimes they get very hot when the symptoms start, a cool washcloth or paper towel on the forehead or back of the neck or front of the neck/chest can help settle things down.
If you are trying to measure BP and P every minute: Some recommended that a blood pressure cuff that is controlled by hand be used2, but then you have to count the pulse also. The reason is that the automated blood pressure cuffs take more time to inflate and take the blood pressure. It is difficult to get the automated cuffs to start and take a blood pressure fast enough to capture the BP and pulse changes every 1 minute
Measuring at 1,3,5 and 10 minutes: The automated cuff works fine for this.
The BP, pulse, all symptoms the person reports, and anything observed (like breathing rate, cyanosis, muscle twitching) are recorded as test data.
When doing the Standing Test, it is very important to explain to the person
1) that they should not move and
2) why - moving muscles changes the blood flow to the heart. It moves blood back up to the hear and
interferes with the test. Moving around decreases the BP & pulse changes & the orthostatic
symptoms or fainting.
Advantage: This can be done in the office. The results are immediately available. It mimics real-life experience.
Challenges: Staff has to be with the person for the whole time and be ready to respond if the person faints or has cardiac problem.
The person has to stand still for the whole time the test is being done. This can be hard to do once the symptoms start.
It can also be hard for children to stand very still.
Comparison of results with the Tilt Table Test. There are some differences in the patient response in the first seconds/minutes of standing up. But they are basically the same as tests and results after the first few minutes.4
Author's Note: There is a clinical value to doing the test for 10 minutes. In 10 minutes, the main causes of Orthostatic Intolerance (OI) can be identified. The delayed problems of orthostatic hypotension and reflex syncope develop later and would not be identified in a 10 minute test. If these are suspected by the history, a full 45 minute Tilt Table Test would be needed.
References
- Strickberger SA, Benson DW, Biaggioni I, Callans DJ, Cohen MI, Ellenbogen KA, et al. AHA/ACCF Scientific statement on the evaluation of syncope. Circulation. 2006;113:316–327
- Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M et al., Guidelines for the diagnosis and management of syncope (version 2009). European Heart Journal (2009); 30: 2631-2671.
- Brignole M. Diagnosis and Treatment of Syncope. Heart 2007: 93; 130-136. Article PDF
- Stewart JM, Medow MS, Alejos JC. Orthostatic Intolerance. Medscape article.
- Grubb BP. Postural tachycardia syndrome. Circulation. 2008;117:2814–2817. Abstract. Article PDF.
- Thieben MJ, Sandroni P, Sletten DM, et al. Postural orthostatic tachycardia syndrome: The Mayo Clinic experience. Mayo Clin Proc. 2007;82:308–313.
Author: Kay E. Jewell, MD
Page Last Updated: June 22, 2012
