Abnormal responses to orthostatic testing in children and adolescents with recurrent unexplained syncope

Syncope in the pediatric age group is a frequent event. Most often the cause is readily apparent--i.e., orthostatic hypotension or a vasovagal event. However, there are a large number of children with frequent recurrent unexplained syncope. Neither history, physical examination, nor standard testing reveals a cause. One hundred four consecutive patients were evaluated by orthostatic testing after standard methods found no cause for the recurrent syncope. Forty-seven (44%) of these 104 patients had syncope produced by orthostatic testing. Twenty-six of the 47 (55%) became syncopal within 5 minutes of testing initiation and 21 of the 47 (45%) after 5 to 11 minutes of testing. These patients had an average decrease of 81.5 mm Hg in blood pressure and a 25 beat/min decrease in heart rate. Of 12 control subjects, none lost consciousness with standing times as long as 14 minutes. Pacing was ineffective in preventing syncope, as two patients with a previously implanted normally functioning pacemaker had recurrent syncope clinically. Syncope was also induced by orthostatic testing, with the pacemaker showing a normal response with pacing as the patient became bradycardic. The syncopal event produced by orthostatic testing occurred with a downward blood pressure trend and a narrowing of the pulse pressure without a significant increase in heart rate. This was followed by a sudden drop in blood pressure and then by bradycardia. There is a group of children and adolescents with recurrent unexplained syncope due to abnormal orthostatic control mechanisms. Orthostatic testing appears helpful in identifying these patients.