Journal of Human Hypertension (2006) 20, 157–162 & 2006 Nature Publishing Group All rights reserved 0950-9240/06 $30.00 www.nature.com/jhh ORIGINAL ARTICLE Nonspecific dizziness: frequency of supine hypertension associated with hypotensive reactions on head-up tilt JE Naschitz1, R Mussafia-Priselac1, Y Kovalev1, N Zaigraykina1, G Slobodin1, N Elias1, S Storch2 and I Rosner3 1Department of Internal Medicine A, The Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; 2Department of Nephrology, The Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel and 3Department of Rheumatology, The Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel The clinical syndrome of supine hypertension asso- The median supine BP was 162/90 mmHg; the median ciated with orthostatic hypotension (OH) in given nadir BP on tilt was 118/78 mmHg. Four SH-HRT patterns individuals is recognized by specialists, but is under- were recognized: (I) SH with typical neurogenic OH diagnosed in the community. The objective of this study (n ¼ 6), (II) SH with vasovagal reaction on tilt (n ¼ 4), (III) was to assess supine hypertension associated with SH with sustained HRT (n ¼ 28), and (IV) SH with mixed hypotensive reactions on head-up tilt (SH-HRT) among orthostatic-vasovagal reaction on tilt (n ¼ 4). Dizziness patients evaluated for nonspecific dizziness. Consecu- on tilt occurred in 25% of patients category III (SH with tive patients with nonspecific dizziness were studied sustained HRT), while appearing universally in other with a 10-min supine 30-min head-up tilt test. Supine SH-HRT patterns. In conclusion, nonspecific dizziness hypertension (SH) was diagnosed when supine systolic may be the chief complaint in patients with SH-HRT, blood pressure (SBP) was X140 mmHg and/or supine a disorder often unrecognized by clinicians. Different diastolic blood pressure (DBP) was X90 mmHg. Hypo- patterns of SH-HRT on HUTT may reflect different tensive reactions on tilt (HRT) were diagnosed when aberrations in cardiovascular homeostasis and may SBP decreased by X30 mmHg on tilt and/or DBP require differentiated management strategies. decreased by X15 mmHg. Of 430 patients tested, 42 Journal of Human Hypertension (2006) 20, 157–162. (9.8%) had SH-HRT. The median age was 67 years; 37 doi:10.1038/sj.jhh.1001947; published online 20 October 2005 had a pretest diagnosis of hypertension, with treatment. Keywords: arterial hypertension; postural hypotension; tilt test Introduction In our experience, some patients with un- explained nonspecific dizziness referred for evalua- The association of supine hypertension (SH) and tion exhibited SH associated with hypotensive orthostatic hypotension (OH) in a given individual reactions on head-up tilt (SH-HRT), which may represents a therapeutic dilemma because treatment have bearing on their symptoms. A retrospective of one of the two aspects of the condition may 1 study was conducted to assess SH-HRT among worsen the other. As expected, published studies patients evaluated for nonspecific dizziness. on SH–OH are to be found by and large in patients with autonomic nervous disorders as well as those with chronic arterial hypertension who present Patients and methods syncope.1–6 In clinical practice, aside from typical OH, a variety of other hypotensive reaction patterns Patients may be recognized in association with diverse The institutional committee for human investigation presenting complaints such as headache and fatigue. at our hospital approved the study. Files of con- secutive patients who underwent a tilt test during the period between January 1999 and January 2004 Correspondence: Professor JE Naschitz, Department of Internal for evaluation of nonspecific dizziness were ana- Medicine A, Bnai-Zion Medical Center, Haifa 31048, P.O. Box lysed. The patients were referred by otorhino- 4940, Israel. E-mail: [email protected] laryngologists or neurologists from a dizziness clinic Received 27 June 2005; revised 23 August 2005; accepted 23 after routine investigation was unrewarding. Pa- August 2005; published online 20 October 2005 tients had neither spontaneous nor gaze nystagmus; Supine hypertension with postural hypotension JE Naschitz et al 158 normal reactions were elicited on head-shaking test, Methods head-impulse test, visual acuity test, Fukuda step- Protocol of the capnography-head-up tilt test ping, Dix-Hallpike and Brandt-Daroff tests.7 Patients (HUTT)15. The tests were carried out from 0800 to with a history of syncope or vertigo were excluded.8 1100 hours, in a quiet environment, at a constant All subjects were fully ambulatory at the time of the room temperature of 22–251C. The subjects had study. Their ages ranged from 18 to 70 years. eaten their usual meals, but smoking and caffeine within 6 h of the examination were restricted. Intake of medications with sympathomimetic activity was Definitions prohibited. Manual BP readings were taken by Syncope is defined as a transient loss of conscious- a physician skilled in the technique recommended ness associated with loss of postural tone, occurring by the American Heart Association.16 A mercury in the upright position and followed by a rapid column sphygmomanometer (Baumanometer, stand- spontaneous recovery on assuming the supine by model 0661-0250) was utilized for measurement position.9 Dizziness is a vague term lumping of the BP, since this is the standard method to which together symptoms of vertigo, lightheadedness, other noninvasive devices of BP measurement are disequilibrium and presyncope.8 Vertigo is typically validated.17 The HR was recorded on an electro- experienced as an illusion of motion, such as cardiographic monitor. The respiratory rate and the whirling imbalance or spatial disorientation. Non- end-tidal pressure of CO2 (ETPCO2) were continu- specific dizziness, which is exclusive of vertigo, is ously monitored with a Datex Normacap infrared often difficult for the patient to describe, frequently capnometer (Finland). The patient lay supine on the referred to as giddiness or lightheadedness, with tilt table, secured to the table at chest, hips and consciousness unaffected during the episode.9 knees using adhesive girdles. The cuff of the BP Supine hypertension was defined for purposes of recording device was attached to the left arm, which the study as systolic blood pressure (SBP) values of was supported at the heart level at all times during 140 mmHg or more and/or diastolic blood pressure the study. Measurements in the supine position values (DBP) of 90 mmHg or more on five measure- were recorded three times at 5 min intervals, at ments during the 10 min recumbence phase before each step the BP being determined as the average of beginning of the tilt test. three paired systolic and diastolic readings. The Hypotensive reactions on tilt (HRT) were consid- table was then gently tilted head-up to an angle of ered, utilizing restrictive criteria, when, at any time 701. The duration of the tilt was 30 min. During during head-up tilt, the SBP decreased by the initial 5 min of tilt, measurements were obtained X30 mmHg or the DBP decreased by X15 mmHg at 1 min intervals and, subsequently, measurements relative to the median of the last supine measure- were continued at 5 min intervals. Repeated ments.10 Several patterns of the HRT were defined measurements were taken at 30 s intervals when and served to classify the patients accordingly: (1) dizziness, faintness or loss of consciousness occurred. typical neurogenic OH characterized by early onset In the event of severe symptoms, the test was of the HRT reaction within 3 min of tilting;11 (2) discontinued. vasovagal reaction characterized by increase of heart Patients exhibiting SH-HRT were assigned to one rate of at least 10 beats per minute after the initial of the patterns described above under hypotensive 3 min of the tilt (consistent with steady-state reactions on tilt. Symptoms appearing on tilt were adaptation) followed later on tilt by a precipitated correlated with HRTs. fall in SBP and DBP, usually, with concomitant 9 decrease in heart rate; (3) sustained HRT character- Statistical analysis. The normality of distribution ized by slow and continuous decrease in BP on of values was assessed with the Shapiro-Wilk postural challenge which did not meet the criteria of W-test. Unpaired Student’s t test or Mann–Whitney OH and were not associated with symptoms during U-test were used, when indicated, to compare 1 the first 3 min of tilt; (4) mixed HRT, a sustained between independent groups of observations. Cor- HRT reaction that resulted in a vasovagal reaction relations between variables were assessed with 9 (also called atypical vasovagal reaction). Pearson’s coefficient of correlation. Two-tailed Hyperventilation was diagnosed by hypocarbia, P-values of 0.05 or less were considered to be measured as end-tidal pressure of CO2. Normal statistically significant. values of end-tidal pressure of CO2 in our laboratory are within the range of 36–40 mmHg. In diagnosing hypocarbia, the ETPCO2 cutoff of 30 mmHg was Results accepted by us.12,13 ‘Sustained hyperventilation’ was diagnosed when end-tidal pressures of CO2 Data were extracted from 430 charts of consecutive o30 mmHg were recorded consecutively for patients who underwent the capnography-HUTT for X10 min. When a brief episode of hyperventilation evaluation of nonspecific dizziness. A total of 42 occurred in association with severe hypotension just patients met the proposed criteria of SH-HRT. There prior to study termination, it was designated ‘HRT- were 16 males and 26 women. Their median age hyperventilatory event’.14 was 67 years (range 47–86 years). The diagnoses Journal of Human Hypertension Supine hypertension with postural hypotension JE Naschitz et al 159 at referral included arterial hypertension in 37 sustained HRT and four patients had mixed HRT.