Postural Hypotension and Its Link to Syncope

Orthostatic hypotension causing syncope?

Hello Director Wu, I have been experiencing postural hypotension with dizziness more noticeably than those around me, but usually, I recover after standing still for a few seconds.
However, a few weeks ago, I experienced a situation where I stood up after lying down for a long time and felt dizzy, my vision went blank, and I lost consciousness, falling down.
I regained consciousness after a few seconds but did not remember falling; I only recalled standing when I heard people nearby calling out.
This same situation occurred about four years ago.
I went to a medical center's cardiology department for further examination, where my electrocardiogram (ECG) was normal, blood tests were normal, and a chest X-ray done a month prior due to chest pain was also reported as normal, so I did not undergo another one.
The 24-hour Holter monitor report revealed rare ventricular premature contractions (VPCs) (28 beats/21:37:11 hours, multiform, with no couplets or salvo episodes) and rare atrial premature contractions (APCs) (4 beats/21:37:11 hours).
Based on responses to other inquiries, VPCs and APCs are considered normal as long as they do not occur too frequently or consecutively.
There is less information on multiform VPCs, but I found a publication from Taipei City Hospital stating that multiform VPCs are associated with high risk.
The Doppler ultrasound report indicated mild mitral regurgitation (MR).
I later found information about vasovagal syncope and recalled an incident six years ago during a morning meeting when I experienced blackouts, cold sweats, and felt like I was about to faint but managed to hold on.
A teacher noticed my pale complexion and advised me to squat down, which helped improve my condition.
The literature also mentioned that postural hypotension is related to vasovagal syncope.
I did not mention the morning meeting incident during my consultation, but I later realized it might be relevant.
I would like to ask, Director Wu, should I be particularly concerned about multiform VPCs, and could my condition possibly be vasovagal syncope? Is there a need for a tilt table test?

S, 20~29 year old female. Ask Date: 2022/02/13

Dr. Wu Xueming reply Cardiology

1.
Is there anything special to pay attention to with multiform VPCs? It is recommended to adjust your daily routine and engage in regular exercise.
Limit caffeine intake from sources such as tea or coffee.

2.
Is it possible that my condition is vasovagal syncope? Is there a need to undergo a tilt table test? Yes, it is possible, and you can go to the hospital to undergo a tilt table test.

Reply Date: 2022/02/13

More Info

Postural hypotension, also known as orthostatic hypotension, is a condition characterized by a significant drop in blood pressure when a person transitions from a lying or sitting position to standing. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and even syncope (fainting). In your case, it appears that you have experienced episodes of dizziness and loss of consciousness upon standing, which aligns with the symptoms of postural hypotension.

The underlying mechanism of postural hypotension involves the body’s inability to adequately regulate blood pressure during changes in posture. When you stand up, gravity causes blood to pool in your legs, which can reduce the amount of blood returning to the heart and subsequently decrease cardiac output. Normally, the body compensates for this by constricting blood vessels and increasing heart rate, but in individuals with postural hypotension, this compensatory mechanism may be impaired.

Your recent episode of syncope after lying down for an extended period and then standing up could indicate that your body was unable to compensate for the sudden change in posture. The fact that you regained consciousness after a few seconds suggests that your body was able to restore blood flow to the brain relatively quickly, but it is concerning that you have experienced similar episodes in the past.

The presence of rare ventricular premature contractions (VPCs) and atrial premature contractions (APCs) noted in your 24-hour Holter monitor report is also worth discussing. While occasional VPCs and APCs can be benign, the multiform nature of the VPCs may warrant further investigation, especially if you are experiencing symptoms like syncope. Multiform VPCs can sometimes indicate underlying cardiac issues, and it is essential to correlate these findings with your symptoms and clinical history.

The relationship between postural hypotension and vasovagal syncope (a type of fainting that occurs when the body overreacts to certain triggers, such as standing for long periods or emotional stress) is significant. Your previous experiences of feeling faint during meetings and the cold sweat you described could suggest a vasovagal response. This response can be triggered by various factors, including prolonged standing, dehydration, or even anxiety.

Given your history and the symptoms you have described, it would be prudent to discuss the possibility of undergoing a tilt table test with your healthcare provider. This test can help evaluate how your body responds to changes in position and can provide valuable information regarding the mechanisms behind your symptoms. Additionally, it may be beneficial to monitor your hydration status, avoid prolonged standing, and consider lifestyle modifications that can help manage your symptoms.

In summary, your symptoms of postural hypotension and syncope, along with the findings of multiform VPCs, should be taken seriously. It is essential to have a thorough discussion with your healthcare provider about your symptoms, the potential link to vasovagal syncope, and whether further testing, such as a tilt table test, is warranted. Monitoring your condition closely and following your doctor's recommendations will be crucial in managing your health effectively.

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