The heartbeat clinic

What is a tilt table test?
Blood pressure is regulated by a set of nerves which operate continuously and
subconsciously and are part of the autonomic nervous system. This set of nerves detects
certain bodily needs and they respond by causing the appropriate changes in blood
pressure. Tilt table testing is designed to evaluate how your body regulates blood pressure
in response to some very simple stresses. The purpose of this part of the autonomic
nervous system is to insure that there is always enough blood going to the brain, and to
distribute blood to other organs according to their needs. For example, during exercise,
blood is delivered preferentially to the muscles, whereas during eating blood is delivered
preferentially to the intestines. These changes in blood pressure are accomplished by
making changes in the way the heart beats and by making changes in the caliber or size
of certain blood vessels. A tilt-table test can help determine the cause of fainting. During
this test, your blood pressure and heart rate are monitored as you lie flat on a table. The
table is then tilted to raise the upper part of your body. The changing angle puts stress on
the part of your nervous system (autonomic nervous system) that regulates your heart rate
and blood pressure. Doctors can evaluate how your body responds to the change in angle,
which is similar to the change when you go from lying down to standing up.
When you stand, gravity causes blood to pool in your leg veins, reducing the amount of
blood that returns to your heart. This causes your blood pressure to drop (orthostatic
hypotension). Normally, your body accommodates this effect by narrowing your blood
vessels and increasing your heart rate. If these mechanisms don't work as they should, the
drop in blood pressure can be severe enough to cause fainting.
Causes of orthostatic hypotension may include diseases that affect the autonomic nervous
system, such as diabetic autonomic neuropathy and Shy-Drager syndrome.
Who needs a tilt table test?
Patients that have symptoms suggestive of a sudden drop in blood pressure may benefit
from the evaluation of blood pressure regulation with a tilt table test. The tilt table test
was originally designed to evaluate patients with fainting spells because many fainting
spells are caused by a drop in blood pressure. Tilt table testing may also be useful for
patients who have symptoms of severe lightheadedness or dizziness which don't actually
cause them to faint, but force them to sit down or lie down. These symptoms, while not
progressing on to an actual fainting spell, may still be indicative of a sudden drop in
blood pressure. Many patients suffering from the chronic fatigue syndrome have
symptoms of lightheadedness and have been referred for tilt table testing.
What does tilt table testing involve?
The first part of a tilt table test evaluates how blood pressure responds to the simple stress
of standing up, or in other words, how the blood pressure responds to the stress of
gravity. Patients are asked to remove their clothing above the waist, put on a hospital
gown, and lie down on a special table. Patients are connected to an electrocardiogram
(EKG) type machine, and have a cuff placed around arm which measures blood pressure.
Sometimes a small intravenous line (IV) is placed into a vein in the arm. We try to make
the setting as relaxing as possible by dimming the lights and by turning on some soft
music in the background. After everything is set up we collect baseline blood pressure
and EKG data for 10 minutes while you lie quietly on the table.
Do I have to have an intravenous line placed?
We have had patients who have an extreme phobia to needles and/or to intravenous lines.
If you have such a phobia, please let us know in advance and we will discuss the options
with you prior to your test.
What protocol is used for the tilt table test?
After we have collected baseline data, the table will tilt you head-up to 80 degrees. You
are tilted upright so that your head is always above your feel; we never tilt patients upside
down. Even though you are lying on a table that is at a 80 degree angle, it feels as though
you are standing on a footboard at the bottom of the table. You will be weight bearing.
You will have two safety straps placed around your waist and your knees to make you
feel secure.
We will be observing your blood pressure and EKG while you are head-up at 80 degrees
for a long period of time, 30 minutes. There is no doubt that remaining still, essentially
standing, for 30 minutes is boring and can be mildly uncomfortable. This prolonged
period of time, however, is important because many of the patients that develop a sudden
drop in their blood pressure do so after 20 minutes. While it would be natural to talk with
you during this boring 45 minute period, talking actually disturbs our measurements of
your EKG and your blood pressure so we ask you to be still and quiet. If you develop
symptoms of any kind, however, we do want you to tell us. We try to make it as
comfortable as possible for you. If you become extremely uncomfortable and cannot go
on we will stop the test. If you complete the 30 minute period of head-up tilt at 80
degrees without developing a drop in your blood pressure, we will lower the table until
you are flat and begin the second part of the test.
The second part of a tilt table test evaluates how blood pressure responds to a stress
caused by a medication that is very much like your body's own adrenaline. Adrenaline is
a hormone that is produced when you exercise or when you are angry or feel stress. The
medication we use is sublingual nitroglycerin as known as Italian Protocol. You may feel
your heart beating a little faster and stronger; some patients say if feels strange because
they feel like they are exercising a little even though they are lying flat. After
nitroglycerin you develop headache. It is usually transient and disappears by the end of
test. After five minutes we tilt the table will again tilt you head-up to 80 degrees. We will
observe you at 80 degrees for 10 minutes. If you complete the 10 minutes of head-up tilt
the table will be returned to the flat position. In some patient we also perform carotid
sinus massage (rubbing the neck to see response of heart rate and blood pressure)
Is this tilt table test protocol similar to the protocols that are being used at other
The most important and universally agreed upon aspects of a tilt table test protocol is that
the test include a prolonged period of head-up tilt in the drug-free state (before
Nitroglycerin is used). In some centers isuprel is used as a provocative drug. We
sometimes use it too.
How long will the tilt table test take?
The duration of the tilt table test depends in part on how you respond. Some patients
demonstrate the reaction that causes their blood pressure to fall suddenly in the first 20
minutes of head-up tilt to 80 degrees. Given the time it takes to set up the equipment and
collect baseline data, the shortest possible test is 30-40 minutes. Other patients finish the
entire protocol without demonstrating any such reaction (a negative test); these patients
therefore finish all three stages of the test. If you finish the entire test, it will take
approximately 2 hours.
Does everyone receive nitroglycerin?
Not everyone will receive nitroglycerin Some patients develop the reaction which causes
a fall in blood pressure during the first part of the test. Once we observe this type of
reaction, the test is terminated and there is no need to administer nitroglycerin.
Unfortunately, we cannot predict ahead of time which patients will require nitroglycerin
and which patients will develop the reaction without nitroglycerin.
What is a positive test?
The interpretation of the test is based on clinical symptoms and clinical picture. A tilt
table test is called positive if a patient develops a drop in blood pressure associated with
symptoms. The symptoms that patients experience are varied and have included
lightheadedness, nausea, a cold and clammy feeling, sweating, a "spacey" feeling, or a
feeling like you are about to black out. Rarely, blood pressure falls without the patient
developing symptoms. In these cases, we try to continue the test until the patient develops
symptoms. If the patient is able to complete the protocol without developing symptoms
despite a fall in blood pressure, we call this a borderline test.
Some patients develop symptoms even though their blood pressure remains normal.
While this would be considered a negative test, we do report the symptoms in the report
and the corresponding blood pressure. In these cases the symptoms are not explained by
changes in blood pressure or heart rate or sometime the changes in blood pressure can be
so transient that are missed by every 2 minute screening.
We also use tilt table to evaluate integrity of autonomic nervous system. Diseases of
autonomic nervous system may present with drop in blood pressure without increase in
heart rate. Sometimes exaggerated heart rate response out of proportion to level of tilt is
seen. This is usually interpreted in the light of presenting history.
What does a positive test mean?
A positive tilt table test means that a patient is susceptible to one of the reactions that can
cause a drop in blood pressure. Some of the reactions can be dangerous and require
treatment, other reactions are benign and may not require treatment. Treatments vary
from medication to a change in diet. The interpretation of the tilt table test is up to your
physician. We provide your physician with the information necessary to interpret the test,
but your physician knows you best and is the best person to interpret your test in the
context of your other medical problems.
Does everyone faint during a tilt table test?
Very few patients faint during a tilt table test. The vast majority of patients that have a
positive test do not faint because we can see their blood pressure falling and we can
return the table to the horizontal position before the patient faints. Typically, patients
experience lightheadedness while their blood pressure is falling and while we are
lowering them to the horizontal position. Rarely, a patient's blood pressure will fall so
fast that we can not get them flat before they faint. These patients who do faint are
usually only "out" for a few seconds and wake up as they are being lowered to the
horizontal position. Patients have safety straps around them to prevent them from falling
off the table if they do faint. There is always a a nurse in the room with the patient during
the periods when the patient is tilted head-up to 80 degrees.
How will I feel after the test?
Many patients who have a positive test feel a little unsettled and sometimes queasy for
the first few minutes after the test. We allow patients to fully recover prior to having
them stand up and get dressed. The vast majority of patients will return to feeling
completely normal within 5 to 10 minutes after the test. Rarely, a patient may continue to
experience weakness or fatigue for a longer period of time after the test. Patients that
have a negative test often report that the test was tiring but otherwise feel fine. If the
patient received isuprel during the test, the effects of isuprel wear off within a few
minutes of stopping the infusion.
Can I drive home after the test?
Many patients will drive home after the test. Since most patients return to feeling normal
within 15 minutes after the test, there is no problem driving home after the test. The test
itself, whether positive or negative, however, is quite tiring. For patients that live some
distance from the hospital, we encourage them to bring someone else along with them
who can drive them home in case the patient feels too tired to drive a long distance.
Why must I not eat before the test?
We ask that patients not eat for at least 4 hours prior to the test. For patients who have
their tests scheduled in the morning, we ask that they not eat after midnight the night
before the test. This is important for a few reasons. The way in which blood pressure is
regulated is slightly different before and after a meal. In order to be able to properly
interpret a test, we need to have the test done after the patient has not eaten for at least 4-
8 hours. In addition, rare patients become quite nauseated during a reaction that causes
blood pressure for fall. While it is extremely uncommon for a patient to actually vomit
during such a reaction, it is important that the stomach be empty. For patients that have
their test scheduled in the afternoon, we ask that they eat only a light breakfast and
nothing for lunch. It is acceptable for a patient to have a few sips of water or juice in the
morning to take a pill or just to moisten the palette.
If I have diabetes, should I take my medication on the morning of the test?
Patients that have diabetes mellitus and are using insulin or taking medication to control
their blood sugar should talk to physician prior to their tilt table test. Usually, patients
with diabetes will have to adjust their insulin or their medication on the day of their tilt
table test in order to avoid their blood sugar from dropping too low.
Will my medications interfere with the test?
Very few medications actually interfere with a tilt table test. However, there are some
medications which may affect the interpretation of the test. Patients should ask their
physician or the physician ordering the tilt table test, whether or not they should continue
to take their medications. Patients with questions about whether or not to take certain
medications prior to the tilt table test should call the Syncope Center.
When will my doctor receive the test results?
The tilt table test report is usually prepared within a day or two of the tilt table test and is
mailed or faxed to the referring physician the next day. In some cases, the physician
performing the tilt table test will speak on the phone with the referring physician about
the results of the test. The report can be sent to additional physicians upon request.
Following is a nice description of Neurally Mediated Hypotension. It has been
reproduced from Johns Hopkins Web page. Many of the syndromes that are diagnosed
by Tilt Table require one of the treatments described below.
Neurally Mediated Hypotension and its Treatment

What is neurally mediated hypotension?

Neurally mediated hypotension is also known by the following names: the fainting reflex,
neurocardiogenic syncope, vasodepressor syncope, the vaso-vagal reflex, and autonomic
dysfunction. Hypotension is the formal medical term for low blood pressure, and syncope
is the term for fainting. Neurally mediated hypotension occurs when there is an abnormal
reflex interaction between the heart and the brain, both of which usually are structurally
When does neurally mediated hypotension lead to symptoms?

Neurally mediated hypotension occurs in susceptible individuals in the following
after prolonged periods of quiet upright posture (such as standing in line, standing in a
shower, or even sitting up for long periods), after being in a warm environment (such as
in hot summer weather, a hot crowded room, a hot shower or bath), immediately after
exercise, after emotionally stressful events (seeing blood or gory scenes, being scared or
anxious). some individuals get symptoms soon after eating, when blood flow has shifted
to the intestinal circulation during the process of digestion.
We are all susceptible to activation of the vaso-vagal reflex that results in a lowered
blood pressure (NMH), but each person's susceptibility is affected by his or her genetic
make-up, dietary factors, psychological make-up, and acute triggers such as infection and
allergy. The clinical problem of NMH occurs when there is sufficiently early triggering
of this reflex to cause symptoms.
How does upright posture lead to these problems?

After a normal individual stands up, blood pools in the legs through the effect of gravity.
To compensate for the lower amount of blood returning to the heart immediately after
standing, the body has a surge of adrenaline (epinephrine). This adrenaline surge leads to
a faster heart rate and to more vigorous heart beats (a familiar feeling we all experience
when we are frightened, for example). The faster heart rate and more vigorous heart
contractions allow the reduced amount of blood returning to the heart to be pumped more
efficiently to vital organs (especially the brain).
In individuals with neurally mediated hypotension, there is a Amiscommunication
between the heart and the brain. Just when the heart needs to beat faster, (to pump blood
to the brain and prevent fainting), the brain sends out the message that the heart rate
should be slowed down, and that the blood vessels in the arms and legs should dilate.
These actions take even more blood away from the central part of the circulation where it
is needed. In response, individuals feel lightheaded or may faint because not enough
blood is getting to the brain. Fainting is helpful, in that it restores a person to the flat
position, removing the pooling effect of gravity on the blood, and allowing more blood to
return to the heart. Following the lightheadedness or syncope, most individuals feel tired
and their mental abilities are somewhat foggy.
Which symptoms can be caused by the neurally mediated hypotension?

Recurrent lightheadedness and fainting are common symptoms, as is an unusual difficulty
with prolonged fatigue after a modest amount of physical activity. This post-exertional
fatigue can last 24-72 hours, and interferes with many daily activities.
We have also observed that chronic fatigue, muscle aches (or fibromyalgia), headaches,
and mental confusion can be prominent symptoms of neurally mediated hypotension even
in individuals who do not faint. The mental confusion takes the form of difficulty
oncentrating, staying on task, paying attention, or finding the right words. Some describe
being in a Amental fog.@ It appears that as long as the fainting reflex is activated
whenever the person stands or sits upright for a period of time, then the blood pressure is
improperly regulated, and these symptoms are the result. Some develop worse fatigue
after such activities as reading and concentrating, and this may be due to the fact that for
some, the veins of the arms and legs dilate, thereby allowing more blood to pool, rather
than constricting in response to mental tasks.
How is neurally mediated hypotension diagnosed?

Neurally mediated hypotension cannot be detected with a routine blood pressure or heart
rate screening. The diagnosis can be made using a prolonged standing test or more
commonly using a tilt table test. Many hospitals and academic centers throughout the
world perform tilt table testing. It allows careful measurement of the heart rate and blood
pressure responses to the head-up position at a 70-degree angle, in an almost standing
position. The usual reason for performing a tilt table test in the past had been for the
evaluation of recurrent fainting. Many people with neurally mediated hypotension
develop adaptations to keep from fainting, such as crossing their legs, fidgeting, or sitting
or lying down when they get lightheaded or tired, but the tilt table test prohibits them
from performing those natural defenses. As a result, lightheadedness, nausea, and fainting
often occur during the tilt table test. Fatigue and malaise often occur for a few days after
the test is performed.
What causes neurally mediated hypotension?

The answer to this question isn't well understood at present, but we suspect neurally
mediated hypotension has genetic origins in many people, because it is not uncommon
for us to find several individuals with neurally mediated hypotension in the same family.
No gene for this condition has been identified.
It is likely that we all could develop neurally mediated hypotension provided that the
conditions were sufficiently severe: for example, if we did not take in enough fluids or
salt, were subjected to extremely prolonged periods of upright posture, or to very warm
environments. The reflex response which results in lowered blood pressure simply occurs
at an earlier point in some individuals.
One of the most common, and treatable problems identified in those with neurally
mediated hypotension is a low salt (sodium) intake in the diet. Salt helps us retain fluid in
the blood vessels, and helps maintain a healthy blood pressure.
Salt has received bad press in the last couple of decades because a high salt diet in some
individuals with high or high-normal blood pressure can contribute to further elevations
in blood pressure, and thereby to heart disease and stroke. This has led to general health
recommendations to cut down on salt. As we are finding, this general recommendation
isn't right for all people. An average adult blood pressure is 120/70, and a blood pressure
is considered elevated if it is above 140/90. Individuals can have neurally mediated
hypotension at a wide range of resting blood pressures. It may be slightly more common
in those whose systolic blood pressure [the top number] is in the 90-110 range, but we
also see it in those whose resting blood pressure is high. For individuals with neurally
mediated hypotension, a low salt intake may be unhealthy, and may move them from
feeling good to developing the symptoms of fatigue and lightheadedness described
earlier. In experimental work earlier this century, severe short term salt depletion led to
fatigue and mental dulling in the adult research subjects.
How is neurally mediated hypotension treated?

Neurally mediated hypotension is most often treated with a combination of increased salt
and water intake in conjunction with drugs that regulate blood pressure. Some drugs work
by allowing the kidneys to retain sodium and others block the body's response to
adrenaline, which can kick-start the blood pressure abnormality. In addition, it is
important to review your current medications with your doctor to ensure that these
medications do not include drugs or vitamins that have the potential to make neurally
mediated hypotension worse. We want to emphasize, however, that the treatments require
persistence, commitment and the willingness to try several possible drugs and
combinations over an extended period of time. Because there is a risk of serious side
effects with some of the drugs such as elevated blood pressure, elevated sodium levels,
lowered potassium levels, or depression, careful monitoring by a physician is required.
Among the drugs that have been found to help improve tilt table responses in patients
with NMH are fludrocortisone (Florinef), beta-blockers (e.g., atenolol), disopyramide
(Norpace), fluoxetine (Prozac), sertraline (Zoloft), ephedrine, pseudoephedrine,
theophylline, methylphenidate (Ritalin), and midodrine. Your treating physician should
work with you to determine the best possible combination for your personal situation. In
general, however, the first step in treating this problem is to increase fluid intake. We
cannot stress this enough. Ourpatients who have discovered the importance of drinking
fluids regularly throughout the day seem to do better than those who don't take this task
For those who have been on a low salt intake we recommend an increase in the amount of
salt they add to their food. The Appendix to this document contains a list of high salt
foods, but specific foods are now conveniently labeled with sodium content for you to
check. For some mildly affected individuals, an increased intake of salt and fluids may be
all that is needed. Most of those with chronic fatigue syndrome and more severe
symptoms require one of several medications in addition to the increased salt and fluid
intake. The increased salt and fluid intake continue regardless of which of these
medications is added.
To be successful, though, the increased salt intake must be accompanied by a sufficient
increase in the intake of water and other fluids (minimum of 2 liters of fluid per day). The
Appendix also describes some of the drugs used for treating neurally mediated
Does treatment cure the problem?
It needs to be emphasized that, when successful, the medications for neurally mediated
hypotension do not cure the problem. Rather, they help control symptoms. When
medications are stopped and when salt intake is reduced, symptoms frequently reappear.
Many of the adolescents and adults with the problem also have symptoms resurface or
worsen at busy or stressful times (making an oral presentation in class, having company
over for Thanksgiving, rushing for a meeting on a hot day and forgetting to drink). Many
women describe a worsening of symptoms in the days around the start of a menstrual
period. The question of what happens over the long term has not been adequately studied,
and the optimal duration of medical treatment is still being worked out. Unfortunately,
despite appropriate doses of the available medications for neurally mediated hypotension,
some individuals with abnormal tilt table tests do not experience an improvement in
symptoms, and some are intolerant of the medications. This emphasizes the need for
more research on this problem. Many women who have NMH describe an improvement
in symptoms when they have been pregnant, and often describe pregnancy as the time
when they felt A the best ever. The improvement may be due to an expansion of blood
volume that occurs with pregnancy.
What other things can I do to get better?

Where practical, avoid circumstances which might bring on symptoms. For example,
shop at non-peak hours to avoid long lines. Take shorter showers and baths and aim for a
cooler water temperature. Avoid saunas, hot tubs, and lying on a hot beach. Avoid
standing still for prolonged periods in hot environments, and on very hot days. Flex your
legs muscles and shift your weight when you are standing still. You may also want to
avoid alcohol because it often leads to dilation of the veins, and this can Asteal@ blood
away from the central circulation. Most with neurally mediated hypotension are quite
intolerant of alcohol. Caffeine intake (including caffeine in soft drinks) affects some
people with NMH in an adverse way, so examine whether caffeine is helping you or
making symptoms worse.
Certain postures and physical maneuvers are helpful in raising blood pressure when
sitting for a prolonged time, mainly by helping use contraction of the leg muscles to
pump blood back to the heart and by compressing the abdomen to reduce the amount of
blood that pools in the intestinal circulation. Dr. Wouter Wieling in Amsterdam and his
colleagues have emphasized the importance of these small changes, as even a small
increase in blood pressure can help maintain an adequate blood flow to the brain. Many
patients have adopted these postures without knowing why. The helpful maneuvers
include: standing with one's legs crossed squatting standing with one leg on a chair bending forward from the waist (such as leaning over a shopping cart) sitting in the knee-chest position sitting in a low chair leaning forward with hands on the knees when sitting. Some of these are less conspicuous than others. Sitting in a low chair (such as a camping stool) is helpful because it causes the legs to be brought up toward the abdomen, and probably reduces the amount of blood pooling in the intestinal circulation. For similar reasons, avoid sitting in a high chair with the legs dangling freely, as there is no resistance to blood pooling unless the muscles are actively contracting. One young woman found she could sit longer without symptoms if she put her feet on a low foot rest (this probably required more leg muscle contraction than regular sitting, and may have also compressed the abdomen better). We have adopted another recommendation from the Dutch group, namely to elevate the head of the bed slightly by 2-4 inches, a position that appears to help the body retain fluid at night rather than lose fluid into the urine. Depending on one's level of comfort with this form of dress, waist-high support hose can prevent some of the excessive pooling of blood in the legs (knee-high support socks may not work as well), as can garments that increase abdominal compression (these work by preventing excessive amounts of blood pooling in the intestinal circulation). Exercise is important in regaining the effects that fitness brings in counteracting NMH. Because exercise can make NMH symptoms worse in the period before effective treatment of the NMH has been found, it must be done carefully at first. When you and your doctor feel you are ready, begin a regular regimen of exercise, finding something that does not make you lightheaded and doing it for brief periods at first, increasing gradually but relentlessly. For example, one girl who had been ill for several years began doing better once two of the NMH medications were working for her. She began on a treadmill, but this made her lightheaded, so she switched to a reclining exercise bike. Although she started with only 2 minutes a day, she increased this in small increments and was up to 30 minutes 3 times a week after about three months. Remember to warm up slowly before, and cool down gradually after exercise. Attention to other medical conditions is crucial to ensuring that the NMH treatments are as effective as they can be. In particular, preventing activation of even mild asthma and allergies has been important in keeping our patients from developing a worsening of symptoms. Endometriosis in women with lower abdominal pain can aggravate NMH, as can sinusitis, anxiety disorders, infections of any sort, and all of these need appropriate medical attention when present. Allergies to food proteins (most commonly cow=s milk protein) have been identified by our colleague Dr. Kevin J. Kelly (now at St. Christopher's Hospital in Philadelphia) as being common in those with NMH, and
substantial improvements can result from strict exclusion of offending foods. Given the
potential dangers of unsupervised diets, be sure to discuss these issues with your doctor.
Again, we want to emphasize strongly that a key part of the therapy is to increase fluid
intake. Those who force themselves to drink extra fluids every couple of hours seem to
do better than those who aren't as serious about increasing their fluid intakes. Keep in
mind that prolonged periods of sleeping (more than 12 hours) may interfere with your
ability to attend to your fluid needs on as regular a basis as would be ideal.
Peter C. Rowe, MD Hugh Calkins, MD Jean Kan, MD
Department of Pediatrics, Department of Medicine, Department of Pediatrics
John Flynn, MD Sally Snader, RN Karen DeBusk, RN
Department of Medicine
Johns Hopkins Hospital, January 1997

An adult requires between 2000 and 3000 milligrams (mg) of sodium to maintain health.
Although health advice in the last two decades has suggested that a low salt intake helps
prevent heart disease and stroke, many individuals with neurally mediated hypotension,
including those who begin with a low normal blood pressure, cannot tolerate this low salt
diet. We believe that individuals with neurally mediated hypotension need to take in
much higher amounts of salt. The exact amount needed is different for each individual,
and is often affected by your taste for salty foods, but it is difficult to take too much,
provided that you have access to lots of fluids if you become thirsty. A few have been
unable to tolerate an increase in sodium intake without developing increased agitation,
but this is uncommon.
Table salt is also an excellent source of sodium, as it has 2300 mg of sodium per
teaspoon. Salt tablets are a way of getting adequate amounts of salt without dramatically
changing the taste of your foods. If you elect to increase your sodium intake with salt
tablets, a good place to start is with one 450 mg tablet three times a day, working up to
two tablets (900 mg) three times a day. Some of our patients report better tolerance of a
buffered salt tablet (Thermotabs, which contain 450 mg sodium chloride and 30 mg
potassium chloride; available from Menley and James, 1-800-321-1834). Salt tablets are
available without a prescription.
As for fluid intake, be sure to drink at least 2 liters of fluid a day. Some people find sports
drinks (which have the advantage of a higher sodium content) to be a good source of
fluids. CeraLyte-70 is a special rehydration fluid designed to provide optimal absorption
of salt and fluid from the gut, and it contains 2.2 grams of sodium chloride per liter of
fluid. It can be obtained at many pharmacies, or by calling toll-free 1-888-237-2598 (1-
The following are high salt foods to help with your needs:
Breads and cereals: Mg sodium

Noodles, potatoes, rice from instant mixes 500
Wheaties (1 cup) 400
Waffles (one) 355
All Bran (2 cup) 285
Cheerios (1 cup) 260
Rice Krispies (1 cup) 260
Saltine crackers (6) 200
Dairy Products:

Parmesan cheese (1 oz.) 450
Processed cheese and cheese spreads (1 oz.) 320
Cottage cheese (2 cup) 230
Fruits and vegetables:

Dill pickle (1) 1430
Tomato juice (8 oz) 800
Sweet pickle (1) 570
Frozen vegetables with special sauces (2 cup) 375
Canned tomato sauce and puree (1/4 cup) 370
Canned vegetables (2 cup) 245
Meat, poultry, fish:

Enchilada (the whole.) 1300
TV dinner (1) 1200
Sweet-n-sour pork (1 serving) 1100
Lasagna (1 serving) 1000
Soup, canned (1 cup) 895
Fish-n-chips (1 serving) 750
Hamburger (1) 690
Hot dog (1) 550
Tuna, canned (2 cup) 535
Corn beef (1 oz) 530
Fried chicken (1 serving) 530
Pizza, cheese (1 slice) 500
Pork-n-beans, chili (1 cup) 460
Luncheon meat (1 slice) 300
Bacon (4 slices) 280
Snacks, condiments:

Pretzel Stix (at Giant), 1 tray (28 g) 1460
Soysauce (1 tbsp) 870
Olives, green (4) 600
Salted nuts (2 cup) 420
Olives, ripe (4) 400
Fruit pie (1/8 pie serving) 355

Formal (generic) name: fludrocortisone
Type of drug: a mineralocorticoid steroid
Action: Florinef acts in the kidney to help the kidney retain sodium that would otherwise
be lost in the urine. It helps the body avidly retain the salt you eat. It does so at the
expense of losing potassium into the urine, so it is important to take in adequate amounts
of potassium each day (a list of foods high in potassium is appended). In addition, we
now recommend potassium supplements when people start on Florinef, regardless of the
serum potassium level, and especially if individuals remain on the drug for several
months. A sustained release potassium preparation (such as K-Dur 10 mEq or K-Dur 20
mEq, or Slow-K 8 mEq) given once daily has been well tolerated by our patients.
Common confusions: Cortisone and fludrocortisone differ. Florinef has none of the anti-
inflammatory properties of cortisone or prednisone, and it has no effect on blood sugar as
cortisone does. Florinef is not a muscle building (anabolic) steroid.
Common side effects: To reduce the chance of Florinef causing an elevated blood sodium
level, make sure to drink lots of fluids while taking Florinef. Some individuals complain
of headache after Florinef and some develop worse CFS symptoms (more
lightheadedness or fatigue), abdominal discomfort of a new type or severity, new chest
discomfort, or tearfulness and depression. The latter occurs in fewer than 1 in 20 patients,
but patients need to be aware of this when they start on the drug, and to know to stop
Florinef if such depressed mood occurs.
Some have found that minor side effects will disappear after a couple of weeks, and it is
worth persevering with the medication provided that the side effects are minor. Some
develop worse acne on Florinef. The tablet has a tiny amount of lactose in it, and may
cause discomfort to those who are extremely allergic to milk protein. Special pharmacies
can compound the drug without lactose (we refer patients to Abrams Royal Pharmacy,
8220 Abrams Rd., Dallas, TX 75231; Tel: 214-349-8000; Fax: 214-341-7966; e-mail:
With high doses, or even low doses over a long period of time, Florinef can lead to an
elevation of blood pressure (BP). For this reason, we recommend that BP be monitored
carefully, especially in the weeks after starting on the drug, and monthly once a stable
dose is achieved.
Suggested doses for CFS patients: Patients with chronic fatigue syndrome who also have
neurally mediated hypotension often have medication sensitivities and appear to benefit
from a gradual increase in their Florinef dose. We recommend beginning with a week of
increasing salt and fluid after tilt testing before starting on Florinef to ensure better
tolerance of the drug. Once you are ready to start, begin with 1/4 tablet per day (0.025
mg). If the 1/4 tablet dose is tolerated for 4-7 days, increase to 2 tablet for 4-7 days, then
to 3/4 tablet or a full 0.1 mg tablet. Doses above this amount may be necessary, but we
usually do not increase the dose to more than 0.2 mg per day. Some patients report that
splitting the dose (half in the morning and half with the evening meal) provides a more
even effect, but occasionally people have to return to a once a day morning dose because
the Florinef causes them to develop insomnia.
Comments: It is important to be sure that you are taking an adequate amount of fluid. We
recommend checking the serum electrolytes about 2-4 weeks after each dosage increase.
Use in pregnancy: consult with your doctor.

Formal (generic) name: atenolol
Type of drug: a beta-blocker
Action: Atenolol blocks the effects of adrenaline (epinephrine), and acts both to decrease
the heart rate and to prevent the forceful heart contractions that kick-start the Afainting
reflex@ in neurally mediated hypotension. Common side effects: Some individuals
complain of headaches or fatigue after atenolol, and others have worse lightheadedness or
worse CFS symptoms in general. Like other beta-blocker drugs, atenolol can lead to
constriction of the airways in individuals with a history of asthma. If cough or wheezing
develop soon after starting the drug, it may need to be stopped. For those with mild
asthma, our impression has been that an inhaled steroid (eg, Azmacort, Flovent) may
allow patients to tolerate the beta-blocker without increased airway reactivity. Atenolol
can also cause emotional depression. Atenolol is less likely than other beta-blocker drugs
(such as propranolol [Inderal]) to lead to nightmares, confusion, and hallucinations.
Atenolol and other beta-blocker drugs can interfere with the body=s ability to correct low
blood sugar, so the drug must be used with extreme caution (if at all) in diabetics. The
activity of the drug can be decreased when it is used in conjunction with non-steroidal
anti-inflammatory drugs such as ibuprofen (Motrin).
Doses: The usual starting dose of atenolol for older adolescents and adults is 50 mg per
day, but doses of up to 100 mg per day are used. We usually aim for 1 mg of atenolol for
every kg of body weight. For example, an individual weighing 62 kg (136 lb) would
likely do well with between 50 and 75 mg of medication per day.
Use in pregnancy: consult with your doctor.

Formal (generic) name: disopyramide

Type of drug: an anti-arrhythmic, anti-cholinergic drug
Action: Norpace blocks the response to adrenaline (epinephrine), and prevents the
forceful heart contractions that occur in neurally mediated hypotension.
Side effects: Some individuals complain of headaches or fatigue after Norpace, and
others have worse lightheadedness. Other possible side effects are dry mouth,
constipation, blurred vision, and impaired urination. This drug can activate glaucoma in
some individuals. Norpace should not be taken with erythromycin, other anti-
arrhythmics, phenothiazines, trimethoprim-sulfamethoxazole, cisapride, or other Class 1a
anti-arrhythmic agents because of the potential for triggering serious heart rhythm
abnormalities. For similar reasons, it should be used with great caution in those on
tricyclic antidepressants. Due to the its ability to reduce the forcefulness of the heart's
pumping action and to trigger arryhthmias, its use should be considered very carefully in
those with heart disease. Use of the drug by those already taking beta-blockers or calcium
channel blockers requires similar caution.
Doses: typically the dose is 100-200 mg of the CR (sustained release) preparation twice
daily, although much higher doses are sometimes tolerated, and lower doses are
sometimes effective. It is preferable to take it on an empty stomach, an hour before or
two hours after eating, but it can be taken with food to reduce stomach irritation. Some
individuals with medication sensitivities need to have the drug started at 100 mg each
morning for a week, with increases of 50 or 100 mg per week (using the 150 mg CR

An adult requires between 1,600 to 2,000 mg. of potassium per day to maintain health.
However, those who are taking Florinef will have a higher need because the drug
depletes potassium. Unlike sodium, manufacturers are not required to list the amount of
potassium on food labels. For this reason, it is important that you become familiar with
the food items listed below. Generally, good sources of potassium include milk, meats,
and fruits, and vegetables. Below is a more complete list of potassium content of various
Beans/Peas: mg. of Potassium

Pork and Beans (12/ cup) 335
Lima Beans (2 cup) 480
Blackeye Peas, Kidney Beans, Lentils (2 cup) 350

Bran buds, All Bran (2 cup) 380
Fiber One, Grape Nuts (2 cup) 240
Raisin Bran (2 cup) 175
Pancakes, Aunt Jemima, whole wheat (3 cakes) 380
Dairy Products:

Milk (1 cup) 400
Yogurt (1 cup) 400 - 500
Instant Breakfasts (Carnation, Delmark, Slimfast,
made with milk) - 1 cup 600 - 800
Hot Cocoa made with milk (1 cup) 600 - 800
Instant Chocolate Pudding (2 cup) 200 - 300
Simple Pleasures frozen dessert (2 cup) 200 - 300
Ice Cream/Ice Milk (1 cup) 200 - 400


Molasses, Blackstrap, 1 Tbsp 585
Spaghetti Sauce, 2 cup 475
Cream soups made with milk (1 cup) 300 - 450
Tomato, Minestrone, Vegetable soups (1 cup) 200 - 300
Split Pea Soup (1 cup) 400
Fruits: mg. of Potassium

Apple juice/Apple cider (1 cup) 300
Apricot Nectar (1 cup) 286
Avocado (2) 550 - 750

Banana (1 Banana) 451
Honeydew melon/Canteloup (1 cup) 460 - 500
Kiwi (1 Kiwi) 250
Nectarine (1 Nectarine) 288
Orange or Grapefruit juice (2 cup) 200
Orange (1 Orange) 240
Pineapple (1 cup) 270
Plum (1 medium) 110
Prunes, cooked (2 cup) 370
Raisins (1 oz. box) 220
Strawberries (1 cup) 250

Beef, Chicken, Pork, Lamb, Fish, and Shellfish
(except imitation crab, 3 2 oz. cooked)
(about the size of a deck of cards) 200 - 400
Chili with beans, 1 cup 500
Enchiladas (chicken, 8.25 oz. entree) 624
Hamburger helper, 1 serving 440
Lasagna, Stouffers, 8 ox. entree 363
Pizza, Lean Cuisine, 5.1 oz. entree 300
Asparagus (2 cup cooked) 280
Broccoli, Carrots or Mixed Vegetables

(frozen, cooked (1 cup) 300 - 350
Brussel Sprouts, Zucchini, Collards, Kale,
Parsnips, frozen cooked (1 cup) 450 - 600
Carrot, 1 whole, raw 233
Cauliflower, Corn, Peas and Carrots
(frozen, cooked (1 cup) 200 - 300
Cucumber, 1 whole 430
Tomato, 1 medium, raw 270
Potato, 1 large, baked 600
Sweet Potato, 1 large, baked 400
V-8 Tomato juice cocktail (1 cup) 570
Neurally mediated hypotension: general reviews
Kaufmann H. Neurally mediated syncope: pathogenesis, diagnosis, and treatment.
Neurology 1995;45(Suppl 5):S12-18.
Kosinski DJ, Grubb BP. Neurally mediated syncope with an update on indications and
usefulness of head-upright tilt table testing and pharmacologic therapy. Curr Opin in
Cardiol 1994;9:53-64.
Sra JS, et al. Neurocardiogenic syncope: Diagnosis, mechanisms, and treatment. Cardiol
Clin 1993;11:183-91.
VanLieshout JJ, Wieling W, Karemaker JM, Eckberg DL. The vasovagal response. Clin
Science 1991;81:575-86.
Autonomic dysfunction: general texts
Bannister R, Mathias CJ. Autonomic Failure, 3rd ed. Oxford: Oxford University Press,
Low PA. Clinical autonomic disorders. Boston: Little Brown, 1993. Robertson D, Low PA, Polinsky RJ, eds. Primer on the Autonomic Nervous System San Diego: Academic Press, 1996 Individual studies of interest Bou-Holaigah I, Rowe PC, Kan JS, Calkins H. Relationship between neurally mediated hypotension and the chronic fatigue syndrome. JAMA 1995;274:961-7. Calkins H, et al. The value of the clinical history in the differentiation of syncope due to ventricular tachycardia, atrioventricular block, and neurocardiogenic syncope. Amer J Med 1995;98:365-73. Calkins H, et al. Clinical presentation and long term follow-up of athletes with exercise induced vasodepressor syncope. Am Heart J 1995;129:1159-64. Calkins H, et al. The economic burden of unrecognized vasodepressor syncope. Amer J Med 1993; 95:473-9. Fredman CS, Biermann KM, Patel V, Uppstrom EL, Auer AI. Transcranial doppler ultrasonography during head-upright tilt-table testing. Ann Intern Med 1995;123:848-9. Manyari DE, Rose S, Tyberg JV, Sheldon RS. Abnormal reflex venous function in patients with neuromediated syncope. J Amer Coll Cardiol 1996;27:1730-5. Rowe PC, Bou-Holaigah I, Kan JS, Calkins H. Is neurally mediated hypotension an unrecognized cause of chronic fatigue. Lancet 1995;345:623-4. Schondorf R, Low PA. Idiopathic postural orthostatic tachycardia syndrome: An attenuated form of acute pandysautonomia. Neurology 1993;43:132-7. Streeten DHP, Anderson GH Jr. Delayed orthostatic intolerance. Arch Int Med 1992;152:1066-72. Tilt test methodology Benditt DG, Ferguson DW, Grubb BP, et al. Tilt tale testing for assessing syncope. J Amer Coll Cardiol 1996;28:263-75. Sheldon R, Killam S. Methodology of isoproterenol-tilt table testing in patients with syncope. J Am Coll Card 1992;19:773-9. Sheldon R. Tilt table testing in the diagnosis and treatment of syncope. CVR&R, September 1994. Natale A, et al. Provocation of hypotension during head-up tilt testing in subjects with no history of syncope or presyncope. Circulation 1995;92:54-8. Treatment: Abe H, et al. Effects of beta-adrenergic blockade on vasodepressor reaction in patients with vasodepressor syncope. Am Heart J 1994;128:911-8. Grubb BP, et al. Usefulness of fluoxetine hydrochloride for prevention of resistant upright tilt induced syncope. PACE 1993;16:458-64. Grubb BP, Samoil D, Kosinski D, Kip K, Brewster P. Use of sertraline hydrochloride in the treatment of refractory neurocardiogenic syncope in children and adolescents. J Am Coll Cardiol 1994;24:490-4. Milstein S, et al. Usefulness of disopyramide for prevention of upright tilt-induced hypotension-bradycardia. Am J Cardiol 1990;65:1339-44. Muller G, et al. Usefulness of metoprolol for unexplained syncope and positive response to tilt testing in young persons. Am J Cardiol 1993;71:592-5. Nelson SD, et al. The autonomic and hemodynamic effects of oral theophylline in patients with vasodepressor syncope. Arch Int Med 1991;2425-9. Ross BA, et al. Abnormal responses to orthostatic testing in children and adolescents with recurrent unexplained syncope. Am Heart J 1991;122:748-54. Scott WA, et al. Randomized comparison of atenolol and fludrocortisone acetate in the treatment of pediatric neurally mediated syncope. Am J Cardiol 1995;76:400-2. Strieper MJ, et al. Efficacy of alpha-adrenergic agonist therapy for prevention of pediatric neurocardiogenic syncope. J Am Coll Cardiol 1993;22:594-7. Susmano A, Volgman AS, Buckingham TA. Beneficial effects of dextro-amphetamine in the treatment of vasodepressor syncope. PACE 1993;16:1235-9. Orthostatic hypotension/postural orthostatic tachycardia: Basso A, et al. Licorice ameliorates postural hypotension caused by diabetic autonomic neuropathy. Diabetes care 1994; 17:1356. Biaggioni I, Robertson RM, Robertson D. Manipulation of norepinephrine metabolism with yohimbine in the treeatment of autonomic failure. J Clin Pharmacol 1994;34:418-23. Mathias CJ. Orthostatic hypotension. Neurology 1995;45(Suppl 5):S6-11.
Hoeldtke RD, Streeten DHP. Treatment of orthostatic hypotension with erythropoietin.
N Engl J Med 1993;329:611-5.
Hoeldtke RD, Horvath GG, Bryner KD. Treatment of orthostatic tachycardia with
erythropoietin. Am J Med 1995;99:525-9.
Jankovic J, et al. Neurogenic orthostatic hypotension: a double-blind, placebo-controlled
study with midodrine. Am J Med 1993;95:38-48.
Low PA, et al. Prospective evaluation of clinical characteristics of orthostatic
hypotension. Mayo Clin Proc 1995;70:617-22.
Onrot J, et al. Management of orthostatic hypotension. Am J Med 1986;80:454-64.
Robertson D, Davis TL. Recent advances in the treatment of orthostatic hypotension.
Neurology 1995;45(Suppl 5):S26-S32.
Robertson D, et al. Clonidine raises blood pressure in severe idiopathic orthostatic
hypotension. Am J Med 1983;74:193-200.
Streeten DHP. Variations in the clinical manifestations of orthostatic hypotension. Mayo
Clin Proc 1995;70:713-4.
Ten Harkel ADJ, et al. Treatment of orthostatic hypotension with sleeping in the head-
up tilt position, alone and in combination with fludrocortisone. J Int Med 1992;232:139-
van Lieshout JJ, ten Harkel ADJ, Wieling W. Physical manoeuvres for combating
orthostatic dizziness in autonomic failure. Lancet 1992;339:897-8.
Wieling W, van Lieshout JJ, van Leeuwe AM. Physical manoeuvres that reduce postural
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