Ann Clin Neurophysiol.  2023 Apr;25(1):27-31. 10.14253/acn.2023.25.1.27.

Autonomic dysfunction in patients with orthostatic dizziness

• Lee H
• Kim HA

• KMID: 2541819
• DOI: http://doi.org/10.14253/acn.2023.25.1.27

Abstract

Orthostatic dizziness is feeling dizzy or lightheaded when standing up. Hemodynamic orthostatic dizziness can be caused by autonomic dysfunction such as orthostatic hypotension or postural tachycardia syndrome. The interpretation of the autonomic function test results in patients with orthostatic dizziness is crucial for diagnosing and managing the underlying condition. The head-up tilt and Valsalva tests are especially important for evaluating adrenergic function in patients with hemodynamic orthostatic dizziness. However, it is important to note that autonomic function tests do not cover the entire diagnostic process, since their findings need to be considered along with the detailed history and physical examination results of the patient because various differential diagnoses exist for orthostatic dizziness. Ensuring appropriate treatment by interpreting the autonomic function test results can help to determine the improvement of and prevents falls from orthostatic dizziness.

Reference

1. Bisdorff A, Von Brevern M, Lempert T, Newman-Toker DE. Classification of vestibular symptoms: towards an international classification of vestibular disorders. J Vestib Res. 2009; 19:1–13.

2. Robertson D. The epidemic of orthostatic tachycardia and orthostatic intolerance. Am J Med Sci. 1999; 317:75–77.

3. Mathias CJ, Mallipeddi R, Bleasdale-Barr K. Symptoms associated with orthostatic hypotension in pure autonomic failure and multiple system atrophy. J Neurol. 1999; 246:893–898.

4. Naschitz JE, Rosner I. Orthostatic hypotension: framework of the syndrome. Postgrad Med J. 2007; 83:568–574.

5. Kim HA, Lee H, Park KJ, Lim JG. Autonomic dysfunction in patients with orthostatic dizziness: validation of orthostatic grading scale and comparison of Valsalva maneuver and head-up tilt testing results. J Neurol Sci. 2013; 325:61–66.

6. Bronstein AM, Guerraz M. Visual-vestibular control of posture and gait: physiological mechanisms and disorders. Curr Opin Neurol. 1999; 12:5–11.

7. Strupp M, Kim JS, Murofushi T, Straumann D, Jen JC, Rosengren SM, et al. Bilateral vestibulopathy: diagnostic criteria consensus document of the classification Committee of the Bárány Society. J Vestib Res. 2017; 27:177–189.

8. Kim HA, Bisdorff A, Bronstein AM, Lempert T, Rossi-Izquierdo M, Staab JP, et al. Hemodynamic orthostatic dizziness/vertigo: diagnostic criteria. J Vestib Res. 2019; 29:45–56.

9. Kim HA, Yi HA, Lee H. Recent advances in orthostatic hypotension presenting orthostatic dizziness or vertigo. Neurol Sci. 2015; 36:1995–2002.

10. Kim HA, Yi HA, Lee H. Spectrum of autonomic dysfunction in orthostatic dizziness. Clin Neurophysiol. 2014; 125:1248–1254.

11. Stewart JM. Common syndromes of orthostatic intolerance. Pediatrics. 2013; 131:968–980.

12. Lee H, Kim HA. Autonomic dysfunction in chronic persistent dizziness. J neurol sci. 2014; 344:165–170.

13. Vernino S, Low PA, Fealey RD, Stewart JD, Farrugia G, Lennon VA. Autoantibodies to ganglionic acetylcholine receptors in autoimmune autonomic neuropathies. N Engl J Med. 2000; 343:847–855.

14. Stewart JM, Medow MS, Cherniack NS, Natelson BH. Postural hypocapnic hyperventilation is associated with enhanced peripheral vasoconstriction in postural tachycardia syndrome with normal supine blood flow. Am J Physiol Heart Circ Physiol. 2006; 291:H904–H913.

15. Owens AP, Low DA, Iodice V, Critchley HD, Mathias CJ. The genesis and presentation of anxiety in disorders of autonomic overexcitation. Auton Neurosci. 2017; 203:81–87.

16. Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011; 21:69–72.

17. Novak P. Assessment of sympathetic index from the Valsalva maneuver. Neurology. 2011; 76:2010–2016.

18. Low PA. Neurogenic orthostatic hypotension: pathophysiology and diagnosis. Am J Manag Care. 2015; 21:s248–s257.

19. Goldstein DS, Sharabi Y. Neurogenic orthostatic hypotension: a pathophysiological approach. Circulation. 2009; 119:139–146.

20. Cheshire WP, Freeman R, Gibbons CH, Cortelli P, Wenning GK, Hilz MJ, et al. Electrodiagnostic assessment of the autonomic nervous system: a consensus statement endorsed by the American Autonomic Society, American Academy of Neurology, and the International Federation of Clinical Neurophysiology. Clin Neurophysiol. 2021; 132:666–682.

21. Norcliffe-Kaufmann L, Kaufmann H, Palma JA, Shibao CA, Biaggioni I, Peltier AC, et al. Orthostatic heart rate changes in patients with autonomic failure caused by neurodegenerative synucleinopathies. Ann Neurol. 2018; 83:522–531.

22. Fanciulli A, Kerer K, Leys F, Seppi K, Kaufmann H, Norcliffe-Kaufmann L, et al. Validation of the neurogenic orthostatic hypotension ratio with active standing. Ann Neurol. 2020; 88:643–645.

23. Cheshire WP Jr, Goldstein DS. Autonomic uprising: the tilt table test in autonomic medicine. Clin Auton Res. 2019; 29:215–230.

24. Gibbons CH, Freeman R. Delayed orthostatic hypotension a frequent cause of orthostatic intolerance. Neurology. 2006; 67:28–32.

25. Mayuga KA, Butters KB, Fouad-Tarazi F. Early versus late postural tachycardia: a re-evaluation of a syndrome. Clin Auton Res. 2008; 18:155–157.

26. Lee H, Kim HA. Orthostatic tachycardia with different onset time in patients with orthostatic intolerance. J Neurol Sci. 2018; 390:166–171.

27. Sheldon RS, Grubb BP 2nd, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015; 12:e41–e63.

28. Fedorowski A, Hamrefors V, Sutton R, van Dijk JG, Freeman R, Lenders JW, et al. Do we need to evaluate diastolic blood pressure in patients with suspected orthostatic hypotension? Clin Auton Res. 2017; 27:167–173.

29. Pavri BB, Ruskin JN, Brooks R. The yield of head-up tilt testing is not significantly increased by repeating the baseline test. Clin Cardiol. 1996; 19:494–496.

30. Chen XC, Chen MY, Remole S, Kobayashi Y, Dunnigan A, Milstein S, et al. Reproducibility of head-up tilt-table testing for eliciting susceptibility to neurally mediated syncope in patients without structural heart disease. Am J Cardiol. 1992; 69:755–760.

31. Lamarre-Cliche M, Cusson J. The fainting patient: value of the head-upright tilt-table test in adult patients with orthostatic intolerance. CMAJ. 2001; 164:372–376.

32. Lee H, Low PA, Kim HA. Patients with orthostatic intolerance: relationship to autonomic function tests results and reproducibility of symptoms on tilt. Sci Rep. 2017; 7:5706.

33. Sandroni P, Benarroch EE, Low PA. Pharmacological dissection of components of the Valsalva maneuver in adrenergic failure. J Appl Physiol (1985). 1991; 71:1563–1567.

34. Kim HA, Yi HA, Hong JH, Lee H. Detailed relationship between the pattern of blood pressure change during the Valsalva maneuver and the degree of orthostatic hypotension during the head-up tilt test in patients with orthostatic intolerance: a retrospective case-control study. Medicine (Baltimore). 2016; 95:e3608.

35. Huang CC, Sandroni P, Sletten DM, Weigand SD, Low PA. Effect of age on adrenergic and vagal baroreflex sensitivity in normal subjects. Muscle Nerve. 2007; 36:637–642.

36. Vogel ER, Sandroni P, Low PA. Blood pressure recovery from Valsalva maneuver in patients with autonomic failure. Neurology. 2005; 65:1533–1537.

37. Arnold AC, Ng J, Raj SR. Postural tachycardia syndrome - diagnosis, physiology, and prognosis. Auton Neurosci. 2018; 215:3–11.

38. Low PA, Sandroni P, Joyner M, Shen WK. Postural tachycardia syndrome (POTS). J Cardiovasc Electrophysiol. 2009; 20:352–358.

39. Thieben MJ, Sandroni P, Sletten DM, Benrud-Larson LM, Fealey RD, Vernino S, et al. Postural orthostatic tachycardia syndrome: the Mayo clinic experience. Mayo Clin Proc. 2007; 82:308–313.

40. Schondorf R, Low PA. Idiopathic postural orthostatic tachycardia syndrome: an attenuated form of acute pandysautonomia? Neurology. 1993; 43:132–137.

41. Low PA. Autonomic nervous system function. J Clin Neurophysiol. 1993; 10:14–27.

42. Fealey RD, Low PA, Thomas JE. Thermoregulatory sweating abnormalities in diabetes mellitus. Mayo Clin Proc. 1989; 64:617–628.