Abnormal orthostatic changes in blood pressure and heart rate in subjects with intact sympathetic nervous function: evidence for excessive venous pooling.

The normal ranges of orthostatic changes in blood pressure and heart rate have been defined in 92 individuals aged 18 to 64 years. In 34 individuals whose symptoms (especially orthostatic light-headedness) suggested cerebral ischemia, but in whom none of the known causes of orthostatic hypotension could be identified, we have found one or more of five theoretically possible orthostatic circulatory derangements: systolic hypotension, diastolic hypotension, diastolic hypertension, excessive narrowing of the pulse pressure, and tachycardia after standing for at least 3 minutes. The orthostatic disorders of blood pressure and heart rate identified in the 34 patients were significantly reduced, almost always into the normal range, by external pressure of 45 to 50 mm Hg applied through an inflatable pressure suit. After labeling with sodium pertechnetate Tc 99m and reinjecting the erythrocytes contained in 3 to 6 ml blood, external gamma counting over a fixed site in the calf, both in the recumbent and in the standing posture, showed excessive gravitational pooling of blood in the legs of five patients with orthostatic diastolic hypertension, of four with orthostatic narrowing of the pulse pressure, and of 10 with orthostatic tachycardia alone. Plasma norepinephrine concentrations were usually normal in recumbency and elevated above normal limits during standing for 15 to 30 minutes in the 18 patients so observed. Red cell mass, plasma volume, and circulating blood volume were subnormal in more than half the seven patients in whom these measurements were made. We conclude that most of the patients with idiopathic sympathicotonic abnormalities of orthostatic blood pressure control have a venous pooling syndrome often aggravated by hypovolemia, the cause(s) of which remains to be determined.