Evaluation of Orthostatic Hypotension: Relationship of a New Self-report Instrument to Laboratory-Based Measures

doi:10.4065/80.3.330

Mayo Clinic Proceedings

Volume 80, Issue 3, March 2005, Pages 330-334

https://doi.org/10.4065/80.3.330 Get rights and content

OBJECTIVE

To compare measured autonomic deficits (composite autonomic severity score [CASS]) with a brief self-report scale we developed to measure severity of symptoms of orthostatic hypotension.

PATIENTS AND METHODS

Patients were recruited in 2 phases: from August to October 2002 and in April 2004. All patients underwent full evaluation in the autonomic laboratory, from which a CASS of autonomic deficits was derived. Patients also completed the 5-item self-report Orthostatic Grading Scale, which inquires about symptoms of orthostatic intolerance due to orthostatic hypotension (eg, severity, frequency, and interference with daily activities).

RESULTS

Of 145 patients, 97 (67%) had orthostatic hypotension. The 5-item scale demonstrated strong internal consistency (coefficient a=.91). Patients with orthostatic hypotension had significantly higher scores on each questionnaire item and CASS subscores than those without orthostatic hypotension. The scale items correlated significantly with each of the CASS subscores, maximally with the CASS adrenergic subscore.

CONCLUSIONS

Orthostatic hypotension is not the only cause of reduced orthostatic tolerance, and some patients may have orthostatic hypotension but be asymptomatic. Results of this study indicate that this 5-item questionnaire is a reliable and valid measure of the severity of symptoms of orthostatic hypotension and that it can supplement laboratory-based measures to provide a rapid, more complete clinical assessment. This questionnaire would also be useful as a brief screening device for orthostatic intolerance to aid physicians in identifying patients who may have orthostatic hypotension.

Section snippets

PATIENTS AND METHODS

Data were collected in 2 stages. In the first stage, we collected data from a consecutive series of patients with neurogenic orthostatic hypotension who were seen in the Mayo Clinic Autonomic Reflex Laboratory in Rochester, Minn, from August to October 2002. Orthostatic hypotension was defined as a sustained reduction in systolic BP of 20 mm Hg or greater within 3 minutes of head-up tilt.⁷ The second stage consisted of a consecutive series of patients referred to the Mayo Autonomic Reflex

SAMPLE CHARACTERISTICS

Our study consisted of 145 patients with a mean age of 60.8 years (SD, 15.5 years) and an even distribution of men and women (52% men). (Three patients were excluded because they had known orthostatic intolerance due to postural tachycardia syndrome; the focus of this study was on orthostatic intolerance due to orthostatic hypotension.) The racial breakdown was 98% white, 1% African American, and 1% Asian, which is representative of our patient population.

Of these 145 patients, 97 (67%) had

DISCUSSION

To our knowledge, this is the first study to compare a self-report grading scale for orthostatic intolerance in patients with putative orthostatic hypotension to a laboratory-measured composite score of autonomic deficits. The simple 5-item questionnaire proved to be of good internal consistency and demonstrated a unitary factor structure. It also had robust correlations with autonomic deficits (CASS), resulting in good sensitivity and specificity compared to the CASS adrenergic subscore. The

CONCLUSIONS

Our 5-item questionnaire provides reasonable correlations with laboratory scores in patients with orthostatic hypotension. Although some correlations were not as robust as we might have expected, the results are not surprising. Orthostatic hypotension may be the dominant clinical symptom in some patients, but in others it may be a minor problem and may be hidden in a complex of other symptoms. The impact of orthostatic hypotension can vary substantially from patient to patient depending on the

APPENDIX 1

Composite Autonomic Scoring Scale^*

Sudomotor subscore
- 1.
  Any of the following alterations
  - a.
    Single QSART site abnormal or
  - b.
    Length-dependent pattern (distal sweat volume <⅓ of forearm or proximal leg values) or
  - c.
    Persistent sweat activity at foot (TST, anhidrosis present but <25%)
- 2.
  Any of the following alterations
  - a.
    Single QSART site <50% of lower limit of normal
  - b.
    Two or more QSART sites reduced (TST anhidrosis, 25%-50%)
- 3.
  Two or more QSART sites <50% of lower

REFERENCES (7)

PA Low et al.
Comparison of the postural tachycardia syndrome (POTS) with orthostatic hypotension due to autonomic failure
J Auton Nerv Syst
(1994)
PA Low et al.
Prospective evaluation of clinical characteristics of orthostatic hypotension
Mayo Clin Proc
(1995)
PA Low
Composite autonomic scoring scale for laboratory quantification of generalized autonomic failure
Mayo Clin Proc
(1993)

There are more references available in the full text version of this article.

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Validation of symptom measures in patients under investigation for postural orthostatic tachycardia syndrome (POTS): The Orthostatic Grading Scale (OGS) and the Symptom Screen for Small-fiber Polyneuropathy (SSS)
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Postural Orthostatic Tachycardia Syndrome (POTS) presents with a range of poorly delineated symptoms across several domains. There is an urgent need for standardized symptom reporting in POTS, but a lack of validated symptom burden instruments. Our aim was to evaluate the psychometric properties of two symptom burden measures: the Orthostatic Grading Scale (OGS) and the Symptom Screen for Small-Fiber Polyneuropathy (SSS), in patients under investigation for suspected POTS.
Psychometric validation study.
Confirmatory factor analysis (CFA) tested the factor structure of the SSS and OGS completed by 149 patients under investigation for POTS. Scale reliability and validity were assessed. The uni-dimensionality of the SSS was assessed through principal component analysis (PCA).
CFA of the OGS revealed that a 1-factor structure had adequate fit. CFA of the SSS revealed that a 5-factor structure had generally appropriate fit supporting the originally proposed 5 factors (1: Gastrointestinal, 2: Somatosensory, 3: Miscellaneous, 4: Microvascular, and 5: Urological). In addition, the SSS demonstrated sufficient uni-dimensionality in the PCA, warranting use of a single total score. Omega coefficients of both measures indicated satisfactory internal reliability (0.668–0.931). Correlations with related constructs (distress (K10 score), r = 0.317–0.404, p < 0.001) and heart rate indices (with the OGS, r = 0.211–0.294, p < 0.05) suggested sound convergent and divergent validity.
Initial evidence suggests that the OGS and SSS have good psychometric properties for use in populations with suspected and confirmed POTS.
The Effects of Noninvasive Vagus Nerve Stimulation on Fatigue in Participants With Primary Sjögren's Syndrome
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Fatigue is one of the most important symptoms needing improvement in Primary Sjögren's syndrome (PSS). Previous data from our group suggest that noninvasive stimulation of the vagus nerve (nVNS) may improve symptoms of fatigue. This experimental medicine study uses the gammaCore device (electroCore) and a sham device to investigate the relationship between nVNS and fatigue in PSS, and to explore potential mechanisms involved.
Forty participants with PSS were randomly assigned to use active (n = 20) or sham (n = 20) nVNS devices twice daily for 54 days in a double-blind manner. Patient-reported measures of fatigue were collected at baseline and day 56: Profile of Fatigue (PRO-F)-Physical, PRO-F-Mental and Visual Analogue Scale of abnormal fatigue (fVAS). Neurocognitive tests, immunologic responses, electroencephalography alpha reactivity, muscle acidosis, and heart rate variability were compared between devices from baseline to day 56 using analysis of covariance.
PRO-F-Physical, PRO-F-Mental, and fVAS scores were significantly reduced at day 56 in the active group only (p = 0.02, 0.02, and 0.04, respectively). Muscle bioenergetics and heart rate variability showed no change between arms. There were significant improvements in digit span and a neurocognitive test (p = 0.03), and upon acute nVNS stimulation, frontal region alpha reactivity showed a significant negative relationship with fatigue scores in the active group (p < 0.01).
We observed significant improvements in three measures of fatigue at day 56 with the active device but not the sham device. Directly after device use, fatigue levels correlate with measures of alpha reactivity, suggesting modulation of cholinergic system integrity as a mechanism of action for nVNS.
Self-reported symptom burden in postural orthostatic tachycardia syndrome (POTS): A narrative review of observational and interventional studies
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Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic health condition affecting mostly women of childbearing age, and significantly impacting their health and quality of life. It is currently poorly understood with no approved licensed treatments. The aim of this systematic review was to contextualize the symptom burden of POTS, and review factors associated with this burden that may guide future treatments. The specific questions were (1) How does symptom burden in POTS compare to the burden in other long term conditions (LTCs), (2) Which factors are associated with POTS symptom burden, and (3) Which interventions show promise in reducing symptom burden in POTS.
Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, APA PsycArticles, OpenGrey) were searched from inception to January 2022 for observational studies reporting on the association between any biological, psychological or social factors and symptom burden, and randomized controlled trials reporting on interventions for symptom burden in adults with POTS. Two reviewers independently conducted eligibility screening, data extraction and quality assessment. A narrative synthesis was undertaken.
5159 entries were screened for eligibility. Twenty-nine studies were included (1372 participants with POTS of a total sample size of 2314, 17 High-, 12 Medium-quality), seventeen were observational and twelve were randomized controlled experimental and intervention trials. Overall methodological quality of the evidence was medium-high but heterogeneity was high and sample sizes modest, allowing moderately robust conclusions. Orthostatic symptom burden was higher in POTS than other LTCs. Serum activity against adrenergic α1 receptors, physical functioning, depression, catastrophizing, prolonged cognitive stress testing and anxiety were significantly associated with symptom burden in medium-high quality studies. Preliminary medium-high quality evidence from predominantly proof-of-concept (n = 11) studies and one 3-month 2 × 2 factorial design trial suggest that compression garments, propranolol, pyridostigmine, desmopressin, and bisoprolol may hold promise in reducing symptom burden. Directions for future research include investigating associated factors over time, the development of complex interventions which address both biological and psychosocial factors associated with symptom burden, and effectiveness trials of these interventions.
POTS symptom burden is high, particularly in relation to orthostatic intolerance when compared to other long-term conditions (LTCs). Despite this burden, there are no effectiveness randomized controlled trials of treatment to reduce symptoms in POTS. This review provides a starting point to understanding researched biological and psychosocial factors associated with this burden. There was however inconsistency in the measurement of symptom burden, lowering the confidence of cross-study inferences. A coherent definition of POTS symptom range, severity and impact along with a validated and reliable POTS-specific instrument is currently lacking. A standardized questionnaire to assess POTS symptom burden as a core outcome measure will help clarify future research and clinical practice.
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Citation Excerpt :
Finally, and most importantly, orthostatic hypotension should be searched repeatedly in patients with reported falls, especially in elderly patients [43]. However, orthostatic hypotension remains largely underdiagnosed, and a 5-item self-report screening questionnaire has been developed to help physicians detect its symptoms and evaluate and follow-up its severity (Table 1) [44]. Orthostatic testing should take place in a quiet room, at a temperature between 20 and 24 °C.
Orthostatic hypotension, defined by a drop in blood pressure of at least 20 mmHg for systolic blood pressure and at least 10 mmHg for diastolic blood pressure within 3 minutes of standing up, is a frequent finding, particularly in elderly patients. It is associated with a significant increase in morbidity and mortality. Although it is often multifactorial, the first favoring factor is medications. Other etiologies are divided in neurogenic orthostatic hypotension, characterized by autonomic failure due to central or peripheral nervous system disorders, and non-neurogenic orthostatic hypotension, mainly favoured by hypovolemia. Treatment always requires education of the patient regarding triggering situations and physiological countermanoeuvers. Pharmacological treatment may sometimes be necessary and mainly relies on volume expansion by fludrocortisone and/or a vasopressor agents such as midodrine. There is no predefined blood pressure target, the goal of therapy being the relief of symptoms and fall prevention.
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¹: This study was supported in part by grants 5K23 RR15537 (P.S.), NS32352, NS44233, and NS43364 (P.A.L.), and T32 HD07447 (L.M.B.-L.) from the National Institutes of Health and M01 RR00585 from the Mayo Clinic General Clinical Research Center.

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ORIGINAL ARTICLEEvaluation of Orthostatic Hypotension: Relationship of a New Self-report Instrument to Laboratory-Based Measures

OBJECTIVE

PATIENTS AND METHODS

RESULTS

CONCLUSIONS

Section snippets

PATIENTS AND METHODS

SAMPLE CHARACTERISTICS

DISCUSSION

CONCLUSIONS

APPENDIX 1

J Auton Nerv Syst

Mayo Clin Proc

Mayo Clin Proc

ORIGINAL ARTICLE
Evaluation of Orthostatic Hypotension: Relationship of a New Self-report Instrument to Laboratory-Based Measures