Diagnostic approach of orthostatic dizziness/vertigo

이형,김현아 대한임상신경생리학회 2020 Annals of Clinical Neurophysiology Vol.22 No.2

This paper introduces new diagnostic criteria and differential diagnosis of orthostatic dizziness to help clinicians to diagnose hemodynamic orthostatic dizziness. Clinicians need to be able to discriminate hemodynamic orthostatic dizziness from other types of dizziness that are induced or aggravated when standing or walking. Measurements of the orthostatic blood pressure and heart rate are important when screening hemodynamic orthostatic dizziness. Detailed history-taking, a physical examination, and laboratory tests are essential for finding the cause of hemodynamic orthostatic dizziness. The differential diagnosis of hemodynamic orthostatic dizziness is crucial because it can be caused by various autonomic neuropathies.

Orthostatic symptoms does not always manifest during tilt-table test in pediatric postural orthostatic tachycardia syndrome patients

Huh, Tae-Eon,Yeom, Jung Sook,Kim, Young-Soo,Woo, Hyang-Ok,Park, Ji Sook,Park, Eun Sil,Seo, Ji-Hyun,Lim, Jae-Young,Park, Chan-Hoo,Park, Ki-Jong,Youn, Hee-Shang The Korean Pediatric Society 2013 Clinical and Experimental Pediatrics (CEP) Vol.56 No.1

Purpose: Chronic day-to-day symptoms of orthostatic intolerance are the most notable features of postural orthostatic tachycardia syndrome (POTS). However, we have encountered patients with such symptoms and excessive tachycardia but with no symptoms during the tilt-table test (TTT). We aimed to investigate whether POTS patients with chronic orthostatic intolerance always present orthostatic symptoms during the TTT and analyze the factors underlying symptom manifestation during this test. Methods: We retrospectively examined patients who presented with POTS at the Gyeongsang National University Hospital between 2008 and 2011. Diagnosis of POTS was based on chronic day-to-day orthostatic intolerance symptoms as well as excessive tachycardia during the TTT. The patients were divided two groups depending on the presentation of orthostatic symptoms during the TTT. Clinical data and the results of the TTT were compared between these groups. Results: In 22 patients, 7 patients (31.8%) did not present orthostatic symptoms during the test. Diastolic blood pressure (BP) was significantly lower in the symptom-positive group. The head-up tilt resulted in a significant increase in diastolic BP in the symptom-negative group (P=0.04), while systolic BP had a tendency to decrease in the symptom-positive group (P=0.06). Conclusion: Significant patients with POTS did not present orthostatic symptoms during the TTT despite having chronic daily symptoms. This finding may be important for establishing definitive diagnostic criteria for pediatric POTS. Development of symptoms during TTT might be related to low diastolic BP and abnormal compensatory responses to orthostasis.

어지럼 클리닉에서의 자율신경부전

조은빈,박기종 대한평형의학회 2018 Research in Vestibular Science Vol.17 No.2

Orthostatic dizziness is a common type of dizziness. In general, orthostatic dizziness is provoked by standing or tilting, and subsided by supine position. The patient with orthostatic intolerance complains multiple symptoms such as dizziness, palpitation, lightheadness, fatigue and rarely syncope. Common orthostatic intolerance is orthostatic hypotension (classic, initial, transient, and delayed orthostatic hypotension) and postural orthostatic tachycardia syndrome. Transcranial Doppler is a noninvasive technique that provides real-time measurement of cerebral blood flow velocity. It can be useful for understanding the relationship between orthostatic symptoms and cerebral autoregulatory function. The reciprocal causal relationship between vestibular and autonomic dysfunction should always be kept in mind.

Autonomic dysfunction in patients with orthostatic dizziness

이 형,Hyun Ah Kim 대한임상신경생리학회 2023 Annals of Clinical Neurophysiology Vol.25 No.1

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.

Orthostatic symptoms does not always manifest during tilt-table test in pediatric postural orthostatic tachycardia syndrome patients

허태은,염정숙,김영수,우향옥,박지숙,박은실,서지현,임재영,박찬후,박기종,윤희상 대한소아청소년과학회 2013 Clinical and Experimental Pediatrics (CEP) Vol.56 No.1

Purpose: Chronic day-to-day symptoms of orthostatic intolerance are the most notable features of postural orthostatic tachycardia syndrome (POTS). However, we have encountered patients with such symptoms and excessive tachycardia but with no symptoms during the tilt-table test (TTT). We aimed to investigate whether POTS patients with chronic orthostatic intolerance always present orthostatic symptoms during the TTT and analyze the factors underlying symptom manifestation during this test. Methods: We retrospectively examined patients who presented with POTS at the Gyeongsang National University Hospital between 2008 and 2011. Diagnosis of POTS was based on chronic day-to-day orthostatic intolerance symptoms as well as excessive tachycardia during the TTT. The patients were divided two groups depending on the presentation of orthostatic symptoms during the TTT. Clinical data and the results of the TTT were compared between these groups. Results: In 22 patients, 7 patients (31.8%) did not present orthostatic symptoms during the test. Diastolic blood pressure (BP) was significantly lower in the symptom-positive group. The head-up tilt resulted in a significant increase in diastolic BP in the symptom-negative group (P =0.04), while systolic BP had a tendency to decrease in the symptom-positive group (P =0.06). Conclusion: Significant patients with POTS did not present orthostatic symptoms during the TTT despite having chronic daily symptoms. This finding may be important for establishing definitive diagnostic criteria for pediatric POTS. Development of symptoms during TTT might be related to low diastolic BP and abnormal compensatory responses to orthostasis.

노인에서 기립성 저혈압에 대한 amezinium methylsulfate의 효과 및 안정성

이상현(Sang-Hyun Lee),배철영(Chul-Young Bae),조주연(Choo-Yon Cho),최규동(Gyu-Dong Choi),김자영(Ja-Yung Kim),오한진(Han-Jin Oh),이상엽(Sang-Yup Lee),박주성(Ju-Sung Park),유희탁(Hee-Tak Yoo),원장원(Jang-Won Won),조경희(Kyung-Hee Cho),김 대한임상노인의학회 2000 대한임상노인의학회지 Vol.1 No.1

연구배경 : 노인에게 흔하게 발생하는 기립성 저혈압은 어지럼증, 낙상을 유발시키는 중요한 원인이지만, 효과적이고 안전한 치료 약물사용이 제한적이어서 치료에 어려움을 겪는 질환이다. Amezinium metilsulfate는 교감신경내로부터 방출된 노르아드레날린의 재흡수를 억제하는 간접형 교감신경자극제로서, 본 연구에서는 기립성 저혈압 노인환자에서 amezinium 투여 후 혈압변화에 미치는 영향을 알아보고자 하였다. 방법 : 1999년 2월 1일부터 8월 31까지 13개 병원 가정의학과 및 노인의학 센터에 내원한 60세 이상 기립성 저혈압 노인환자 100명을 대상으로 치료군 41명은 amezinium 10mg을 하루 2회 2주간 투여하고, 대조군 59명은 기립성 저혈압 환자교육자료만 제공한 후 2주후 평가 비교하였다. 평가항목은 혈압, 맥박, 기립후 환자의 자각증상, 의사의 개선도 평가, 혈액 및 소변검사와 심전도로서 처치 전후에 시행하여 비교하였다. 결과 : 어지럼증의 호전은 치료군에서 60.0%, 대조군에서 42.9%, 심계항진은 치료군에서 47.1%, 대조군에서 25.0%, 오심은 치료군에서 56.3%, 대조군에서 30.0% 발한은 치료군에서 45.5%, 대조군에서 28.6%, 호흡곤란은 치료군에서 41.7%, 대조군에서 20.0%의 호전을 보였으나 두 군간에 통계학적 유의한 차이는 없었다. 의사가 시행한 총체적 개선도 평가에서 치료군은 61.0%, 대조군은 18.6%의 호전을 보여 유의한 차이를 보였다(p<0.001). 처치전과 처치후의 혈압 및 맥박변화는 치료군에서 수축기와 이완기 혈압이 모두 유의한 차이를 보였고(p<0.001), 대조군에서 이완기혈압에서 유의한 차이를 보였다(p<0.01). 맥박변화는 치료군과 대조군 모두 유의한 차이를 보이지 않았다. 앙와위 상태를 기준으로 기립 후 혈압차이를 산출하고, 처치 전후 혈압차이 변화량을 계산하였다. 치료군에서 대조군보다 기립 후 수축기와 이완기 혈압차이 변화량이 더 많았으나, 기립 3분 후 이완기혈압차이 변화량만이 통계적으로 유의한 차이를 보였다(p<0.05). Amezinium 투여후 환자가 호소한 증세는 졸리움, 불안증, 변비, 상복부 불쾌감, 홍조 각 1예였으나 치료를 중단할 정도로 심한 증세는 없었고, 투약 중단 후 소실되었다. 혈액 및 소변검사와 심전도검사에서 투약 후 약물과 관련되어 이상소견을 보인 경우는 없었다. 결론 : 기립성 저혈압을 가진 노인에서 amezinium metilsulfate의 투여 후 맥박의 유의한 변화나 안정시 혈압 변화가 없는 상태에서 심한 부작용 없이 기립 후 혈압저하를 억제하는 효과가 있었다. Background : Orthostatic hypotension is common condition in the elderly, but choice to treat it pharmacologically is limited because of expected side effects. Amezinium metilsulfate is an indirectly acting symathomimetic drug, which affects postganglionic sympathetic neurons, selectively inhibiting both intraneural monoamine oxidase and reuptake of norepinephrine. The purpose of this study was to assess the efficacy of amezinium for orthostatic hypotension in the elderly. Methods : A total of 100 patients aged 60 years or older with orthostatic hypotension participated in this multicenter study. The treatment group (n=41) received amezinium 10mg bid for two weeks and was given a patient education brochure about orthostatic hypotension. The control group received only the patient education brochure. We evaluated the patients blood pressure, pulse rate at supine, one and three minutes after standing. Assessments of orthostatic symptoms and laboratory examination were done before and after intervention. Results : In patients with orthostatic symptoms, amezinium treated patients showed improvements in dizziness (60.0%), palpitation (47.1%), nausea (56.3%) whereas the control group reported improvements in dizziness (42.9%), palpitation (25.0%), nausea (30.0%), without statistical significance. In the global symptom evaluation by the investigator, the amezinium group had more improvements compared to the control group (p<0.001). Standing systolic and diastolic blood pressure after treatment with amezinium was significantly increased without changes in supine blood pressure and pulse rate. Only standing diastolic blood pressure in the patient educated control group was increased. We calculated net differences of orthostatic changes of blood pressure and pulse rate after intervention. The differences of standing change of blood pressure in the amezinium group were greater than those in the control group. Especially the difference in diastolic blood pressure at 3 minutes after standing was significant. Conclusion : This study indicates that amezinium is efficacious and safe in the treatment of orthostatic hypotension in the elderly, without change of resting blood pressure and pulse rate.

Patterns of Orthostatic Blood Pressure Changes in Patients with Orthostatic Hypotension

석흥열,김유환,김하욤,김병조 대한신경과학회 2018 Journal of Clinical Neurology Vol.14 No.3

Background and Purpose The objective of this study was to determine the patterns of blood pressure (BP) changes during the head-up tilt (HUT) test, particularly in terms of its clinical significance for patients with orthostatic hypotension (OH). Methods OH was divided into four categories based on systolic BP changes occurring within the first 10 minutes of the HUT test: sustained orthostatic hypotension (SOH), progressive orthostatic hypotension (POH), orthostatic hypotension with partial recovery (OHPR), and transient orthostatic hypotension (TOH). Results In total, 151 patients were analyzed: 65 with SOH, 38 with POH, 21 with OHPR, and 27 with TOH. POH patients exhibited the greatest reduction in systolic BP after HUT and were also the most likely to develop symptoms requiring early termination of the HUT test (42.1%, p<0.001). Additionally, SOH patients exhibited smaller heart-rate variation with deep breathing values (p=0.003) and Valsalva ratios (p=0.022) compared to POH patients. The sweat volume was greatest in OHPR patients. Conclusions Clinical characteristics, including the findings of autonomic function tests, differed between the OH patient groups. This might reflect differences in the underlying pathophysiologic mechanisms. Determining the patterns of BP changes during the HUT test may facilitate the development of effective management strategies in patients with OH.

Diagnosis and management of neurogenic orthostatic hypotension

주우희,신동인 대한임상신경생리학회 2023 Annals of Clinical Neurophysiology Vol.25 No.2

Orthostatic hypotension is a sustained and pathological drop in blood pressure upon standing. Orthostatic hypotension can be due to non-neurogenic conditions or autonomic disorders. Impaired baroreflex-mediated vasoconstriction and insufficient release of norepinephrine play key roles in the pathophysiology of neurogenic orthostatic hypotension. Its common symptoms mainly related to inadequate cerebral blood flow include dizziness, lightheadedness, and syncope. It is crucial to differentiate neurogenic orthostatic hypotension from non-neurogenic orthostatic hypotension. For the management of neurogenic orthostatic hypotension, physicians should implement non-pharmacological methods and, if possible, reverse combined non-neurological conditions. Depending on severity of symptoms, pharmacological intervention may be tried after or with non-pharmacological methods. Its management should be individualized based on intensity of symptoms, comorbid conditions, drug side effects, and etiology. In this review, we discuss the definition, pathophysiology, clinical approach, and management of neurogenic orthostatic hypotension

소아에서의 기립성 저혈압과 기립성 체위성 빈맥증후군: 임상 양상 및 신경생리검사 비교

김윤겸(Yun Kyum Kim),박지현(Ji Hyun Park),최희정(Hee Joung Choi),김준식(Joon Sik Kim) 대한소아신경학회 2017 대한소아신경학회지 Vol.25 No.3

Purpose: The clinical characteristics and neuropsychological tests of orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS) in children were compared. Methods: From August 2011 to April 2015, we enrolled patients who visited hospital with dizziness or syncope. According to the results of head-up tilt test (HUTT), the patients were classified into 4 groups; OH group, POTS group, normal group I who had no orthostatic symptom during HUTT, and normal group II who had orthostatic symptom during HUTT. Results: Eighty-eight patients were enrolled with 11(12.5%) in OH group, 13(14.7%) in POTS group, 49(55.7%) in normal group I and 15(17.0%) in the normal group II. During HUTT, the temporal changes of systolic, diastolic, and mean blood pressure of OH group were significantly different from those of POTS group, normal group I, and normal group II. Heart rate changes after tilt showed increase trend in all 4 groups and there was no significant different between OH and POTS group. In normal group II, the temporal changes of diastolic and mean blood pressure were similar to those in POTS group and were significantly different from normal group I. In the autonomic nervous system test, the heart rate response to deep breathing (HRDB) was significantly different between normal group I and II. Conclusions: In pediatric OH patients, heart rate may be increased with blood pressure fall. And if orthostatic symptoms are associated with HUTT, we should not exclude OI even if the test result do not meet the criteria for diagnosis.

허혈성 뇌졸중에서 기립성 저혈압 회복의 저해 인자

정호중,김기찬,심영주,엄문섭,홍진영,이종화 대한재활의학회 2008 Annals of Rehabilitation Medicine Vol.32 No.3

Objective: To determine the time period and factors inhibiting recovery of orthostatic hypotension during head up tilt with ischemic stroke patients.Method: Fourty two ischemic stroke patients with orthostatic hypotension were included. Blood pressure and heart rate were taken after resting in the supine position for 10 minutes and again after standing for one minute every week. Age, gender, body mass index, laboratory findings, diabetes mellitus, anti-hypertensive use, side of involved hemisphere and K-MBI were obtained.Results: The numbers of orthostatic hypotension patients were significantly decreased at 3rd week. Non recovering group until 3rd week were older in age and had higher plasma creatinine level. On the other hand, body mass index and K-MBI were lower than the group without orthostatic hypotention. Multivariate analysis revealed that age, body mass index, anti-hypertensive medication were independently associated factors for resistant orthostatic hypotension during head up tilt.Conclusion: For 7 weeks, especially at 3rd week, the numbers of orthostatic hypotension patients significantly decreased. Age, BMI, and antihypertensive medication were inhibitiing factors for recovery of orthostatic hypotension.