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Active standing

Recommendations Classa Levelb

Indications

Intermittent determination by sphygmomanometer of BP and HR while supine and during active standing for 3 min are indicated at initial syncope evaluation.20,103,104 I C

Continuous beat-to-beat non-invasive BP and HR measurement may be preferred when short-lived BP variations are suspected, such as in initial OH.20,103,104 IIb C

Diagnostic criteria

Syncope due to OH is confirmed when there is a fall in systolic BP from baseline value >_20 mmHg or diastolic BP >_10 mmHg, or a decrease in systolic BP to <90 mmHg that reproduces spontaneous symptoms.6,20,103,104 I C

Syncope due to OH should be considered likely when there is an asymptomatic fall in systolic BP from baseline value >_20 mmHg or diastolic BP >_10 mmHg, or a decrease in systolic BP to <90 mmHg, and symptoms (from history) are consistent with OH.6,20,103,104 IIa C

Syncope due to OH should be considered likely when there is a symptomatic fall in systolic BP from baseline value >_20 mmHg or diastolic BP >_10 mmHg, or a decrease in systolic BP to <90 mmHg, and not all of the features (from history) are suggestive of OH.6,20,103,104 IIa C

POTS should be considered likely when there is an orthostatic HR increase (>30 b.p.m. or to >120 b.p.m. within 10 min of active standing) in the absence of OH that reproduces spontaneous symptoms.6,20,103,104 IIa C

Syncope due to OH may be considered possible when there is an asymptomatic fall in systolic BP from baseline value >_20 mmHg or diastolic BP >_10 mmHg, or a decrease in systolic BP to <90 mmHg, and symptoms (from history) are less consistent with OH.6,20,103,104 IIb C

BP = blood pressure; b.p.m. = beats per min; OH = orthostatic hypotension; HR = heart rate; POTS = postural orthostatic tachycardia syndrome. aClass of recommendation. bLevel of evidence.

Table 8 Association of orthostatic intolerance and orthostatic hypotension

History of syncope and orthostatic complaints

Highly suggestive of OH: syncope and presyncope are present during standing, absent while lying, and less severe or absent while sitting; a predilection for the morning; sitting or lying down must help; complaints may get worse immediately after exercise, after meals or in high temperatures; no “autonomic activation” Possibly due to OH: not all of the features

highly suggestive of OH are present

Supine and standing BP measurement Symptomatic abnormal BP fall Syncope is due to OH (Class I) Syncope is likely due to OH (Class IIa)

Asymptomatic abnormal BP fall Syncope is likely due to OH (Class IIa) Syncope may be due to OH (Class IIb)

No abnormal BP drop Unproven Unproven

BP = blood pressure; OH = orthostatic hypotension. Downloaded from academic.oup.com/eurheartj/article/39/21/1883/4939241 by guest on 07 October 2026