Dysautonomia and Orthostatic Tolerance

What is Dysautonomia?

Dysautonomia refers to a range of conditions that impact the autonomic nervous system (ANS)—the body’s control system for involuntary processes like heart rate, blood pressure, digestion, and temperature regulation. 

Dysautonomia can occur for two reasons:

• Primary Dysautonomia: idiopathic or genetic, occurs independently and may not have a known cause.

• Secondary Dysautonomia: resulted from or related to another condition

  • Common secondary causes include:

    • Autoimmune conditions

    • Viral infections such as COVID-19

    • Trauma or surgery- especially involving the brainstem or spinal cord

    • Chemotherapy or toxins

When the ANS isn’t working properly, individuals can experience symptoms that affect their ability to function day-to-day. This includes issues related to orthostatic tolerance (how well the body manages standing upright).

Classifications of Dysautonomia:

Dysautonomia is an umbrella term that encompasses several distinct conditions and understanding the differences between each condition is vital for appropriate medical management. Below are the 4 different classifications I most commonly see in the clinic that affects an individuals upright tolerance. 

• Postural Orthostatic Tachycardia Syndrome (POTS):

  • A rapid sustained increase in hear rate greater than 30bpm above resting supine heart rate, without substantial change in blood pressure. 

  • Symptoms should be present for greater than 3 months.

  • POTS is commonly used interchangeably with dysautonomia but they are NOT the same thing. Individuals can have dysautonomia but NOT POTS. 

•  Orthostatic Hypotension (OH):

  • A drop in systolic pressure greater than or equal to 20 mmHg or a drop in diastolic pressure greater than or equal to 10mmHg after 3 minutes of standing.

• Orthostatic Hypertension (OHT):

  • An increase in systolic pressure greater than or equal to 20 mmHg or an increase in diastolic pressure greater than or equal to 10mmHg after 3 minutes of standing.

  • Often overlooked, this form can lead to symptoms like dizziness and palpitations, similar to those seen in hypotension, but from the opposite end of the spectrum.

• Orthostatic Intolerance (OI):

  • A broad term used to describe symptoms that occur with prolonged standing, but do not necessarily meet the diagnostic criteria for POTS, OH, or Orthostatic Hypertension.

  • Often times individuals will have significant symptoms but will be undiagnosed and untreated due to not meeting appropriate diagnostic criteria. 

Testing for Appropriate Dysautonomia Classification:

Diagnosis should involve testing that assesses your blood pressure and heart rate response to position changes over a prolonged period. Testing should be performed without the use of HR or BP modulating medications for 3-5 days prior to testing for most accurate results.

Diagnostic tools include:

• Tilt Table Testing:

  • A controlled procedure that helps assess how your heart rate and blood pressure react when you move from a lying position to standing. 

  • Currently tilt table tests are hard to acquire as most autonomic labs are booked out for 1-2 years! 

• Active Stand Test:

  • A simpler and more accessible option for many. This involves measuring vital signs and symptoms as you transition from lying to standing, helping healthcare providers assess your body's response to changes in posture.

  • Orthostatic vitals should be taken at 2 minute intervals for at least 10 minutes to provide an accurate diagnosis. 

  • This test can provide important information to guide your treatment without needed to wait for a tilt table test. 

  • My goal in using the active stand test and conservative treatment is to help you manage your dysautonomia effectively—so that by the time you could get into an autonomic lab, it may no longer be necessary as your symptoms are well managed!

Conservative Management (No Matter the Type):

While the labels and specifics of dysautonomia vary, conservative management techniques can be effective in improving symptoms and quality of life. These strategies are often the first line of defense and can make a significant difference in managing the condition.

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Stay tuned for Part 2 where we will dive into the conservative treatment approach for dysautonomia.