Orthostatics - Still Mostly Useless

Written by Clay Smith

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In patients ≥60 years, abnormal orthostatic vital signs (OVS) did not predict 30-day serious outcomes.

Why does this matter?
We recently discussed OVS in depth. They have a limited role but are so often present in normal people and absent in people with true volume loss, that it renders them largely useless. Yet, the 2017 AHA syncope guidelines still recommend they be done. Please take a moment to read Thomas Davis’ comments (at the bottom) when he reviewed my summary this week. He is spot on.

Orthostatics - still mostly useless
This was a planned secondary analysis of a different syncope study with 1,974 patients ≥60 years who had OVS performed. Of these, 37.7% had abnormal OVS (the usual HR/BP criteria). They compared 30-day serious outcome* among those who were orthostatic and those who were not. There was no difference, 15.3% OVS abnormal vs 14.7% OVS normal; adjusted OR 0.82 (95%CI, 0.62-1.09). Bear in mind, this secondary analysis did not include all the patients in the original study, because not all of them had OVS done. So, there is some selection bias inherent to this analysis. Those who had OVS performed tended to be older, have coronary disease, heart failure, dyspnea, abnormal ECG, higher physician risk estimate, and were more likely to be hospitalized. When adjusting for these factors, there remained no difference. I was able to find one advantage to performing OVS in Appendix D of the article - they may “protect” patients from cardiac intervention, 52 (4.2%) 17 (2.3%) p=0.034. I say this tongue in cheek, but one wonders…

*30-day serious outcome includes: “cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death.”

Source
Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. Am J Emerg Med. 2019 Mar 25. pii: S0735-6757(19)30186-X. doi: 10.1016/j.ajem.2019.03.036. [Epub ahead of print]

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Reviewed by Thomas Davis - His comments this week were so helpful that I have included them here in full:

“There were data that suggested OVS may be associated with increased mortality, which prompted this study. But it feels like the research has gotten side tracked from the whole reason AHA recommends OVS. AHA recommends OVS not as a way to risk stratify for mortality/admission (although many falsely use it that way) but rather to identify patients whose presenting symptoms may be controlled through lifestyle and medication adjustments (as orthostatics may be a sign of neurogenic OH or volume depletion). Therefore, as I read the AHA guidelines, they never intended OVS to be a tool to address mortality but rather quality of life. I'd like to see more research focused on whether OVS actually achieves this outcome--not mortality. After all, there are 2 outcomes we care about in medicine: 1) dead vs alive and 2) happy vs sad.”

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