Correspondence
in an emergency department bed: a randomized controlled trial. Ann
Emerg Med. 2017;69:298-307.
2. Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital
emergency department without being seen by a physician. Causes and
consequences. JAMA. 1991;266:1085-1090.
Discriminatory Value of Orthostatic
Vital Signs in the Emergency Department
Evaluation of Syncope
To the Editor:
We read with interest the recently published
guidelines put forth in Circulation in regard to the
evaluation of syncope patients.1 The task force, which
included an American College of Emergency Physicians
working committee, should be commended for
addressing such a difficult topic. However, we do have a
question for the authors in regard to the utility of
orthostatic vital signs in the emergency department (ED)
evaluation of syncope. The authors state that “the
physical exam should include determination of
orthostatic heart rate and blood pressure changes in lying
and sitting positions, on immediate standing, and after 3
minutes of upright posture.”
Do the authors believe orthostatic vital signs have sufficient
predictive value to help emergency physicians differentiate
syncope patients at high risk for adverse events from those who
are not? We ask because the only support for this
recommendation cited in the article is a consensus statement
defining “positive” orthostatic vital signs.2 No evidence is
presented to support the ability of a positive test result to
discriminate causes of syncope associated with adverse
outcomes from low-risk causes, the primary goal of syncope
evaluation in the ED. The authors identify 9 syncope
risk-scoring systems used to risk-stratify patients.1 None of the
9 uses orthostatic vital signs as a predictor of adverse outcomes.
Furthermore, one of these studies specifically evaluated a
“20 mmHg postural drop” in blood pressure in syncope
patients and found that it was not an independent predictor
of 30-day serious events.3 This may be because orthostatic
vital signs lack specificity for serious causes of syncope. Raiha
et al4 found that 28% of asymptomatic elderly patients
exhibited positive orthostatic vital signs. This was confirmed
by Ooi et al,5 who demonstrated that 51.5% of
asymptomatic nursing home patients had positive orthostatic
vital signs. Skinner et al6 and Stewart7 made similar
observations about young, otherwise healthy adolescents. In
addition, multiple authors have documented the failure of
orthostatic vital signs maneuvers to detect patients with
known intravascular volume contraction as a result of both
hemorrhage and vomiting.8-10
438 Annals of Emergency Medicine
For these reasons, orthostatic vital signs poorly
discriminate between syncope patients who require further
diagnostic testing and those who do not. Additionally,
performing these maneuvers on all syncope patients in the
ED may lead to confirmation bias and early closure for
patients who have significant pathology but histories
consistent with benign causes. Without evidence of
discriminatory value, universal performance of orthostatic
vital signs on syncope patients in the ED wastes time, may
mislead diagnosticians, and fails to inform the decision in
regard to which patients benefit from further diagnostic
testing or inpatient services.
LT Adam S. Bloom, MC, USN
CDR John J. Devlin, MC, USN
Department of Emergency Medicine
Naval Medical Center Portsmouth
Portsmouth, VA
http://dx.doi.org/10.1016/j.annemergmed.2017.05.020
Funding and support: By Annals policy, all authors are
required to disclose any and all commercial, financial, and
other relationships in any way related to the subject of this
article as per ICMJE conflict of interest guidelines (see
www.icmje.org). The authors have stated that no such
relationships exist.
The views expressed in this article are those of the authors
and do not necessarily reflect the official policy or position
of the Department of the Navy, Department of Defense, or
the US government.
We are military service members. This work was prepared
as part of our official duties. Title 17 USC 105 provides
that “Copyright protection under this title is not available
for any work of the United States Government.” Title 17
USC 101 defines a US government work as a work
prepared by a military service member or employee of the
US government as part of that person’s official duties.
1. Shen W, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for
the evaluation and management of patients with syncope: a report of the
American College of Cardiology/American Heart Association Task Force
on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation.
2017; http://dx.doi.org/10.1161/CIR.0000000000000498.
2. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the
definition of orthostatic hypotension, neurally mediated syncope and
the postural tachycardia syndrome. Auton Neurosci. 2011;161:46-48.
3. Reed M, Newby D, Coull A, et al. The ROSE (Risk Stratification of
Syncope in the Emergency Department) study. J Am Coll Cardiol.
2010;55:713-721.
4. Raiha I, Luutonen S, Piha J, et al. Prevalence, predisposing factors and
prognostic importance of postural hypotension. Arch Intern Med.
1995;155:930-935.
Volume 70, no. 3 : September 2017

5. Ooi W, Barrett S, Hossain M, et al. Patterns of orthostatic blood pressure
change and the clinical correlates in a frail, elderly population. JAMA.
1997;277:1299-1304.
6. Skinner J, Driscoll SW, Porter CB, et al. Orthostatic heart rate and
blood pressure in adolescents: reference ranges. J Child Neurol.
2010;25:1210-1215.
7. Stewart JM. Transient orthostatic hypotension is common in
adolescents. J Pediatr. 2002;140:418-424.
Volume 70, no. 3 : September 2017
Correspondence
8. McGee S, Abernethy WB, Simel DL. The rational clinical examination. Is
this patient hypovolemic? JAMA. 1999;281:1022-1029.
9. Witting MD, Wears RL, Li S. Defining the positive tilt test: a study of
healthy adults with moderate acute blood loss. Ann Emerg Med.
1994;23:1320-1323.
10. Johnson D, Douglas D, Hauswald M, et al. Dehydration and orthostatic
vital signs in women with hyperemesis gravidarum. Acad Emerg Med.
1995;2:692-697.
Annals of Emergency Medicine 439