Feeling dizzy when you stand up? Simple muscle techniques can effectively manage symptoms of initial orthostatic hypotension

Two cost-free, non-drug treatments can improve a patient’s quality of life, report scientists in a novel study published in Heart Rhythm


Philadelphia February 9, 2022

Feeling lightheaded upon standing up due to initial orthostatic hypotension (IOH), or a transient decrease in blood pressure and increase in heart rate, is a common but poorly understood condition. A new study offers two simple cost- and drug-free techniques to effectively manage symptoms of IOH and improve quality of life by activating lower body muscle before or after standing. The research appears in Heart Rhythm, the official journal of the Heart Rhythm Society, the Cardiac Electrophysiology Society, and the Pediatric & Congenital Electrophysiology Society, published by Elsevier.

Syncope, lightheadedness, dizziness, or loss of consciousness from IOH affects up to 40% of the general population (all ages), while presyncope is probably even more common. Despite this, the condition is relatively understudied and there is minimal information available about the underlying mechanisms or symptom management and treatment. Currently, there are very few options available to patients with IOH and no pharmacological treatments. The most common recommendations have been to stand up slowly or sit up first before standing.

“Almost everyone has probably experienced some lightheadedness at some time after standing up,” explained lead investigator Satish R. Raj, MD, MSCI, FHRS, Professor of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. “For some people this is a frequent occurrence and may happen several times a day, which can be very frightening and negatively impact their quality of life.

“We wanted to explore this further and provide novel and effective symptom management techniques with the goal of improving the IOH patient’s quality of life," added Dr. Raj.

This study investigated physical maneuvers before or after standing and their efficacy in reducing the drop in blood pressure as well as the symptoms typically seen in IOH patients upon standing. Study participants included 24 young women (mean age 32 ± 8 years) with a high burden history of fainting immediately after standing and more than four episodes of presyncope or syncope per month. The study participants were required to have a significant drop in systolic blood pressure of at least 40mmHg upon standing to fulfill the diagnostic criteria of IOH on the study day. Two participants had inadequate heart rate recordings and were excluded from the analysis.

Twenty-two study participants completed three sit-to-stand maneuvers including a stand with no intervention (control), and two interventions. Researchers found that both lower body muscle preactivation (thighs) through repeated knee raises prior to standing (PREACT) and lower body muscle tensing (thighs and buttocks) through leg crossing and tensing immediately after standing (TENSE) effectively improve the blood pressure drop. This led to a reduction in symptoms upon standing. They found that the PREACT maneuver accomplished this by increasing cardiac output, while the TENSE maneuver did so by increasing stroke volume.

Investigators determined both lower body muscle preactivation (PREACT) and lower body muscle tensing (TENSE) effectively reduced the drop in mean arterial pressure upon standing and improved symptoms of initial orthostatic hypotension. Left: Schematic diagram of the three interventions: no intervention (Control), PREACT, and TENSE. Right: Drop in mean arterial pressure following Control (blue), PREACT (pink), and TENSE (purple) (Credit: Heart Rhythm).

“Our study provides a novel and cost-free symptom management technique that patients with IOH can use to manage their symptoms,” noted first author Nasia A. Sheikh, MSc, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary. “Since it is a physical maneuver, it simply requires the lower body limbs, which patients can utilize at any time and from anywhere to combat their symptoms.”

“Our study demonstrates the physiology of IOH and assesses the utility of physical maneuvers that can help the IOH patient manage their symptoms. A diagnosis of IOH is identified by patients as the critical first step to empowering them to understand and master their symptoms and thus minimize the disruptions to daily living caused by this common, but not commonly understood, condition,” added co-investigator Mary Runté, PhD, University of Lethbridge, Lethbridge, AB, Canada.

In an accompanying editorial, Bert Vandenberk, MD, PhD, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary; and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; and Carlos A. Morillo, MD, FHRS, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, commented that “PREACT and TENSE provide an elegant and simple effective symptom relief option for patients with IOH.”

However, they noted, “The study needs to be validated in men, as well as being explored in the elderly where multiple confounders should be addressed. Understanding the role of cardiopulmonary mechanoreceptors should also provide further mechanistic insights into the effects of these simple yet very effective physiologic maneuvers.”

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Notes for editors
The article is “Lower body muscle preactivation and tensing mitigate symptoms of initial orthostatic hypotension in young females,” by Nasia A. Sheikh, MSc, Shaun Ranada, BSc, Matthew Lloyd, PhD, Dallan McCarthy, BSc, Karolina Kogut, BSc, Kate M. Bourne, BSc, Juliana G. Jorge, MD, Lucy Y. Lei, BHSc, Robert S. Sheldon, MD, PhD, FHRS, Derek V. Exner, MD, MPH, FHRS, Aaron A. Phillips, PhD, Mary Runté, PhD, and Satish R. Raj, MD, MSCI, FHRS (https://doi.org/10.1016/j.hrthm.2021.12.030). It is openly available at https://www.heartrhythmjournal.com/article/S1547-5271(21)02524-8/fulltext.

This work was supported by the Canadian Institutes of Health Research (CIHR; Ottawa, ON, Canada) grant MOP142426 and support from the Vanderbilt Institute for Clinical and Translational Research (NIH UL1-TR000445).

The editorial is “Symptom reduction in initial orthostatic hypotension – Time to get physical!” by Bert Vandenberk, MD, PhD, and Carlos A. Morillo, MD, FHRS (https://doi.org/10.1016/j.hrthm.2021.12.031). It is openly available at https://www.heartrhythmjournal.com/article/S1547-5271(21)02525-X/fulltext.

The articles appear online in advance of Heart Rhythm, volume 19, issue 4 (April 2022) published by Elsevier.

Full text of the articles is also available to credentialed journalists upon request; contact Jane Grochowski at +1 406 542 8397 or hmsmedia@elsevier.com. Journalists who wish to interview the study authors should contact Kelly Johnston, Senior Communications, Media Specialist, Cumming School of Medicine, University of Calgary, at +1 403 617 8691 (mobile) or kelly.johnston2@ucalgary.ca. To reach the editorial’s authors for comment, contact Carlos A. Morillo, MD, FHRS, at carlos.morillo@ucalgary.ca.

About Heart Rhythm
Heart Rhythm, the official Journal of the Heart Rhythm Society, the Cardiac Electrophysiology Society, and the Pediatric & Congenital Electrophysiology Society, is a unique journal for fundamental discovery and clinical applicability. It integrates the entire cardiac electrophysiology (EP) community from basic and clinical academic researchers, private practitioners, engineers, allied professionals, industry, and trainees, all of whom are vital and interdependent members of our EP community. www.heartrhythmjournal.com

About the Heart Rhythm Society
The Heart Rhythm Society is the international leader in science, education, and advocacy for cardiac arrhythmia professionals and patients, and the primary information resource on heart rhythm disorders. Its mission is to improve the care of patients by promoting research, education, and optimal healthcare policies and standards. The Heart Rhythm Society is the preeminent professional group representing more than 6,500 specialists in cardiac pacing and electrophysiology from more than 70 countries. www.HRSonline.org

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