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Syncope and orthostatic hypotension: early markers of cardiac disease in the general population
  1. Martin H Ruwald
  1. Correspondence to Dr Martin H Ruwald, Department of Cardiology, Herlev-Gentofte Hospital, Hellerup 2900, Denmark; mruwald{at}

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In the general population, syncope and orthostatic hypotension (OH) are frequent events that often lead to hospitalisation or a visit to the emergency department. However, as a broad symptom, it is currently unclear whether they are independent risk markers for adverse prognosis or if syncope and OH are actually the initial symptom leading to diagnosis of severe underlying cardiac disease.

Naturally some syncopal events will lead to diagnosis of severe underlying cardiac disease resulting in adverse prognosis, but for the majority, it is considered a benign event without need for any further scrutiny. Within recent years, research has, however, suggested an association between seemingly benign syncopal events in otherwise healthy individuals and increased mortality and early morbidity.1 Syncope is also related to a higher risk of subsequent falls and injury and, when diagnosed, cardiac syncope is particularly associated with increased mortality as compared with non-cardiac syncope.2 The prognosis in the general population is therefore thought to be determined by an underlying cardiac disease,3 which may be unknown at the time of first syncope and therefore syncope might actually be the initial symptom leading to diagnosis.

OH is also a common disorder, with or without signs of underlying neurodegenerative or cardiovascular disease. OH is diagnosed with an orthostatic challenge and requires a decrease in blood pressure of at least 20/10 (systolic/diastolic) mm Hg on standing. It broadly reflects a structural and dysfunctional regulation of the sympathetic system and is highly associated with age-related degeneration and polypharmacy.4 The prevalence and incidence are age dependent and clinicians often face OH as a complication and side effect of the pharmacological treatment of hypertension, ischaemic heart disease and heart failure. This …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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