Tina Sheehy

Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension

INTRODUCTION Orthostatic hypotension (OH) is associated with troublesome symptoms and increased mortality. It is treatable and deserving of accurate diagnosis. This can be time consuming. The current reference standard for its diagnosis is head-up tilt (HUT) testing with continuous beat-to-beat plethysmography. Our objective was to assess the accuracy of sit-stand testing with semi-automatic sphygmomanometry for the diagnosis of OH. DESIGN Retrospective test of diagnostic accuracy. METHODS This was a retrospective study performed using a database maintained by a busy syncope unit. HUT testing was performed using an automated tilt table with Finometer monitoring. A 3 min 70 degrees HUT was performed following 5 min supine. Sitting blood pressure (BP) was measured following 3 min rest. Standing BP was measured within 30 s of assuming the upright posture. The results of sit-stand testing were compared with HUT testing as a reference standard. Both tests happened within 5 min of each other and patients underwent no intervention between tests. RESULTS From a total of 1452 consecutive HUTs, we identified 730 with pre-test measures of sitting and standing BP. The mean age of this group was 70.57 years (SD = 15.1), 62% were female. The sensitivity of sit-stand testing was calculated as 15.5%, specificity as 89.9%, positive predictive value as 61.7%, negative predictive value as 50.2% and the likelihood ratio as 1.6. The area under the Receiver Operator Curve was 0.564. CONCLUSION We have demonstrated that sit-stand testing for OH has very low diagnostic accuracy. We recommend that the more time-consuming reference standard method of diagnosis be used if the condition is suspected.

Treatment of Vasodepressor Carotid Sinus Syndrome with Midodrine: A Randomized, Controlled Pilot Study

Objectives: To evaluate the efficacy of treatment of the vasodepressor form of carotid sinus hypersensitivity (carotid sinus syndrome (CSS)) with midodrine.

The changing face of orthostatic and neurocardiogenic syncope with age

AIM Reports of the outcomes of syncope assessment across a broad spectrum of ages in a single population are scarce. It is our objective to chart the varying prevalence of orthostatic and neurocardiogenic syncope (NCS) as a patient ages. METHODS This was a retrospective study. All consecutive patients referred to a tertiary referral syncope unit over a decade were included. Patients were referred with recurrent falls or orthostatic intolerance. Tilt tests and carotid sinus massage (CSM) were performed in accordance with best practice guidelines. RESULTS A total of 3002 patients were included (1451 short tilt, 127 active stand, 1042 CSM and 382 prolonged tilt). Ages ranged from 11 to 91 years with a median (IQR) of 75 (62-81) years. There were 1914 females; 1088 males. Orthostatic hypotension (OH) was the most commonly observed abnormality (test positivity of 60.3%). Those with OH had a median (IQR) age of 78 (71-83) years. Symptomatic patients were significantly younger than asymptomatic (P = 0.03). NCS demonstrated a bimodal age distribution. Of 194 patients with carotid sinus hypersensitivity, the median age (IQR) was 77 (68-82) years. Those with vasovagal syncope (n = 80) had a median (IQR) age of 30 (19-44) years. There were 57 patients with isolated postural orthostatic tachycardia syndrome. Of the total patients, 75% were female. They had a median (IQR) age of 23 (17-29) years. CONCLUSION We have confirmed, in a single population, a changing pattern in the aetiology of syncope as a person ages. The burden of disease is greatest in the elderly.

Near death and neurocardiogenic syncope

We report the case of an 18-year-old female who presented as an out-of-hospital ventricular fibrillation cardiac arrest. She required ICD insertion and recovered without deficit. Following recurrent syncopal episodes we diagnosed the co-existence of Neurocardiogenic syncope.

Recurrent loss of consciousness

An electrocardiograph and beat-to-beat blood pressure recordings were performed during right sided supine carotid sinus massage on a 78 year old man (figure)⇓. He reported frequent episodes of loss of consciousness, which were typically of sudden onset followed within minutes by rapid recovery to full health. Some were associated with jerking movements of his limbs. He linked some of these episodes to turning his head. He had no important comorbidities but had recently fallen and sustained a fracture. Simultaneous beat-to-beat blood pressure (above) and electrocardiograph (below) tracings performed during right sided supine carotid sinus massage. Arrow indicates onset of 5 second carotid sinus massage. Image created with BeatScope software, using data obtained from a Finometer device ### Short answers