Use of Valsalva Maneuver to Detect Late-Onset Delayed Orthostatic Hypotention, 2023, Jin-Woo Park et al

Abstract

Background:
Standard autonomic testing includes a 10-minute head-up tilt table test to detect orthostatic hypotension. Although this test can detect delayed orthostatic hypotension (dOH) between 3 and 10 minutes of standing, it cannot detect late-onset dOH after 10 minutes of standing.

Methods:
To determine whether Valsalva maneuver responses can identify patients who would require prolonged head-up tilt table test to diagnose late-onset dOH; patients with immediate orthostatic hypotension (onset <3 minutes; n=176), early-onset dOH (onset between 3 and 10 minutes; n=68), and late-onset dOH (onset >10 minutes; n=32) were retrospectively compared with controls (n=114) with normal head-up tilt table test and composite autonomic scoring scale score of 0.

Results:
Changes in baseline systolic blood pressure at late phase 2 (∆SBPVM2), heart rate difference between baseline and phase 3 (∆HRVM3), and Valsalva ratio were lower and pressure recovery time (PRT) at phase 4 was longer in late-onset dOH patients than in controls. Differences in PRT and ∆HRVM3 remained significant after correcting for age. A PRT ≥2.14 s and ∆HRVM3 ≤15 bpm distinguished late-onset dOH from age- and sex-matched controls. Patients with longer PRT (relative risk ratio, 2.189 [1.579–3.036]) and lower ∆HRVM3 (relative risk ratio, 0.897 [0.847–0.951]) were more likely to have late-onset dOH. Patients with longer PRT (relative risk ratio, 1.075 [1.012–1.133]) were more likely to have early-onset than late-onset dOH.

Conclusions:
Long PRT and short ∆HRVM3 can help to identify patients who require prolonged head-up tilt table test to diagnose late-onset dOH.

https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.122.20098

 

Interesting!

This study is about whether a longer tilt table test is needed. But I wonder if these same factors - pressure recovery time (PRT) and heart rate variability (HRV) - would also be useful for deciding whether a NASA lean test is sensitive enough vs. needing a tilt table test?

I asked one of the doctors on twitter about whether a NASA lean test could detect NMH (Neurally Mediated Hypotension, aka, a delayed drop in blood pressure, which is what I think what they are calling "late-onset delayed orthostatic hypotension"). I believe the reply was that the NASA lean test can sometimes detect this but it will miss cases where the blood pressure drop is delayed.

I always wonder about false negatives, where a person thinks they don't have any type of orthostatic intolerance, but if the test had been longer it would have shown a drop in their blood pressure. My blood pressure drop happened after 20-30 minutes ( two different tilt table tests).