Orthostatic dysregulation

Classification according to ICD-10
I95.1	Orthostatic hypotension Orthostatic dysregulation
ICD-10 online (WHO version 2019)

The orthostatic hypotension ((Gr.) Orthostasis = upright stand), according to ICD-10 -Classification a disorder of the circulatory system and is considered as a form of hypotension .

Other names are: orthostatic hypotension (in humans an unusually low blood pressure that sets in when getting up from a sitting or lying position) and orthostasis syndrome .

In orthostatic dysregulation there is a malfunction of the orthostatic response . In healthy people, this orthostasis reaction ensures that the cardiovascular system works properly even in an upright position. As a result of the malfunction, symptoms such as dizziness, palpitations, impaired visual function, nausea, weakness and drowsiness occur in an upright position, which force you to sit down or lie down, and the symptoms quickly subside. In some sick people, circulatory syncope (short-term unconsciousness) occurs.

The resting blood pressure when lying or sitting can be decreased , normal or increased regardless of the orthostatic dysregulation .

Standing becomes a problem

Illustration of an orthostatic syncope. When standing up, the blood builds up in the lower part of the body. If you lie down - or if you fall over during a syncope (brief fainting) - the blood comes back to the brain.

Symptoms of orthostatic dysregulation

The symptoms of orthostatic dysregulation occur after a sudden change in position, especially from lying down to standing. If you stand for a long time, the symptoms worsen.

The following symptoms may include: a. in orthostatic dysregulation occur:

• general symptoms: inner restlessness, sweating, paleness, feeling cold, acrocyanosis , nausea
• Cardiac symptoms: feeling of oppression, racing heart, palpitation
• Neurological symptoms: drowsiness and emptiness in the head, headache, dizziness, ringing in the ears, unsteadiness and unsteadiness, blurred vision, eye flickering, tunnel vision.

The symptoms force the patient to sit down or lie down, and the symptoms usually subside quickly. Syncope (short-term unconsciousness) occurs in some patients . These syncope can lead to serious falls or accidents.

Diagnosis of orthostatic dysregulation

A blood pressure monitor is sufficient for the Schellong test

A careful anamnesis already gives clear indications of the disease. A Schellong test or a tilt table examination confirm the diagnosis. If there is a tendency to syncope, a long-term ECG should also be performed.

Forms of orthostatic dysregulation

The ICD-10 classification, which is binding for doctors, does not differentiate between the various forms of orthostatic dysregulation. The distinction between the different forms is therefore not necessary and only makes sense in individual cases.

Orthostatic hypotension

The types of orthostatic dysregulation associated with a drop in blood pressure after standing upright are commonly referred to as orthostatic hypotension .

Epidemiology of orthostatic hypotension

Orthostatic hypotension occurs predominantly in old age. Orthostatic hypotension manifests itself in around 25% of those over 65 years of age.

Pathophysiology of orthostatic hypotension

Orthostatic hypotension is defined as a marked drop in blood pressure within three minutes of changing position from lying down to standing. The systolic blood pressure falls by more than 20 mmHg or to a value below 90 mmHg absolute. The diastolic blood pressure falls by more than 10 mmHg. In addition, the symptoms of orthostatic dysregulation appear.

Forms of orthostatic hypotension

• Asympathikotone orthostatic hypotension
  When a sympatheticotonic orthostatic hypotension, also hypo adrenergic orthostatic hypotension , the systolic blood pressure decreases after the position changes by more than 20 mmHg and the diastolic blood pressure by more than 10 mmHg. The heart rate remains the same or is decreased.
  The cause is damage to the autonomic nervous system which leads to insufficient or no activation of the sympathetic nervous system . This results in a loss of vasoconstriction and an increase in heart rate.
  Asympathetic orthostatic hypotension often has a chronically progressive course that is difficult to correct therapeutically.
• Sympathetic orthostatic hypotension
  In sympathetic orthostatic hypotension, the systolic and diastolic blood pressure drops by more than 20 mmHg and the heart rate increases by more than 16 beats per minute after standing up.
  The cause is usually central hypovolemia . The body tries to compensate for the missing blood volume by increasing the heart rate, i.e. by very strong activation of the sympathetic nervous system.
• Vasovagal dysfunction
  The vasovagal dysfunction, (from Latin vas = vessel and nervus vagus ), is also known as neurocardial dysfunction or neurally mediated orthostatic dysfunction . This is characterized by a neurocardial reflex-like drop in blood pressure with a slowed heartbeat and the resulting reduction in cerebral blood flow with unconsciousness after prolonged standing.

Postural tachycardia syndrome (POTS)

A tilt table examination confirms the diagnosis (tilt table from 1922)

The postural tachycardia syndrome (POTS) ((Latin) posture = concerning the posture) is also known as postural orthostatic tachycardia syndrome or orthostatic intolerance .

Postural tachycardia syndrome is a special form of orthostatic dysregulation. In postural tachycardia syndrome, in contrast to the other forms of orthostatic dysregulation, there is no drop in blood pressure when changing to the upright position. In the case of postural tachycardia syndrome, blood pressure stabilization while standing is achieved more by cardiac activation than by narrowing of the blood vessels in the legs.

Epidemiology of Postural Tachycardia Syndrome

In contrast to the other forms of orthostatic dysregulation, postural tachycardia syndrome predominantly affects younger women. Most of the sick are between 15 and 50 years old, 80% are women. The prevalence of postural tachycardia syndrome is estimated at around 0.2 percent, which corresponds to around 160,000 sufferers in Germany.

Pathophysiology of postural tachycardia syndrome

Postural tachycardia syndrome is defined as an increase in heart rate of at least 30 beats / min within 10 minutes after standing upright or to at least 120 beats / min absolute. Typically, the heart rate increases continuously while standing. The mean blood pressure hardly changes, there is no pathological drop in blood pressure, i.e. H. the systolic blood pressure does not decrease by more than 20 mm Hg, the diastolic blood pressure by not more than 10 mm Hg. In relation to the normal orthostatic reaction, the systolic blood pressure can decrease somewhat more and the diastolic blood pressure can increase somewhat more. When standing for a long time, the symptoms of orthostatic dysregulation increasingly appear.

Causes of Postural Tachycardia Syndrome

About 50% of the sick had a viral infection before the onset of symptoms. There is a certain comorbidity with mitral valve prolapse .

Postural tachycardia syndrome is not a mental illness. However, the symptoms can trigger anxiety. Fear and panic, in turn, can exacerbate the symptoms of postural tachycardia syndrome through hyperventilation .

Postural tachycardia syndrome is caused by a disorder of the autonomic nervous system . A loss of nerve endings of the sympathetic nervous system in the heart ( autonomic cardiac denervation ) could be demonstrated in some of the patients . Also increased were norepinephrine values at noradrenaline transport defect or the occurrence of acetylcholine receptor - antibodies in a subset of patients demonstrated.

In postural tachycardia syndrome, peripheral vasoconstriction is insufficient. An autonomic nervous system disorder is a systemic disorder that causes a variety of different dysfunctions. These dysfunctions are causally connected with one another and influence one another. Postural tachycardia syndrome therefore has several causes:

• A disturbed norepinephrine reuptake leads to a dysfunction of the sympathetic nervous system of the lower extremities.
• A disturbed water and sodium retention by the kidneys results in hypovolemia . As the blood sinks into the lower extremities when standing (venous pooling), the reduced central blood volume reaches critical values ​​that trigger massive baroreflex activation with the corresponding tachycardia .
• A change in the pressure conditions in the blood vessels of the lower extremities changes the capillary filtration . As a result, more fluid escapes into the surrounding tissue when standing, which in turn increases the already existing hypovolemia.
• Compared to healthy people, people with postural tachycardia have a greatly reduced blood flow to the brain while standing. This reflexively leads to deeper and faster breathing ( hyperventilation ), which in turn is the cause of hypocapnia .

Prognosis of postural tachycardia syndrome

80% of 40 patients reported a significant improvement in their orthostatic symptoms at least 18 months after the initial examination.

Differential diagnosis

Postural orthostatic tachycardia syndrome is often confused with inadequate sinus tachycardia , although the symptoms are almost identical. Occasionally, patients have both syndromes at the same time.

See also

Shy-Drager syndrome

Web links

POTS: Postural Tachycardia on YouTube , accessed December 4, 2019.

literature

• Lois Jovanovic, Genell J. Subak-Sharpe: Hormones. The Medical Handbook for Women (Original Edition : Hormones. The Woman's Answerbook. Atheneum, New York 1987). From the American by Margaret Auer, Kabel, Hamburg 1989, ISBN 3-8225-0100-X , pp. 317 f., 382.

Individual evidence

1. ↑ ^{a b c} ICD-10-2016 ( Memento of the original from August 8, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved August 19, 2016 
2. ↑ ^{a b c d e f g h i j k l m n o} Medicine-Knowledge-Online, Orthostatic Hypotension. Retrieved August 19, 2016.
3. ↑ ^{a b c d e f g h i j k l m n o p q r} Rolf R. Diehl: Postural tachycardia syndrome. In: Deutsches Ärzteblatt, vol. 100, issue 43, October 2003. Retrieved August 19, 2016.
4. ↑ ^{a b c} Postural tachycardia due to anxiety disorder? In: www.medical-tribune.ch. Retrieved August 20, 2016.
5. ^ German Society for Neurology: Robert Wartenberg Prize of the DGN. Retrieved August 19, 2016.

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