Are small observational studies sufficient evidence for a recommendation of head-up sleeping in all patients with debilitating orthostatic hypotension? MacLean and Allen revisited after 70 years

  • Wouter Wieling
  • S. R. Raj
  • R. D. Thijs


  1. 1.
    Bannister R, Ardill L, Fentem P (1969) An assessment of various methods of treatment of idiopathic orthostatic hypotension. Q J Med 152:377–395Google Scholar
  2. 2.
    Borst JGG, Borst-de Geus A (1963) Hypertension explained by Starling’s theory of circulatory homeostasis. Lancet I:677–682CrossRefGoogle Scholar
  3. 3.
    Cooper VL, Hainsworth R (2008) Head-up sleeping improves orthostatic tolerance in patients with syncope. Clin Auton Res 18:318–324PubMedCrossRefGoogle Scholar
  4. 4.
    Corcoran AC, Browning JS, Page IH (1942) Renal hemodynamics in orthostatic hypotension: effects of angiotonin and head-up bed. J Am Med Ass 119:793–798Google Scholar
  5. 5.
    Evidence based Medicine Working Group (1992) Evidence based medicine, a new approach to teaching the practice of medicine. J Am Med Assoc 268:2420–2425CrossRefGoogle Scholar
  6. 6.
    Fan CW, Gasparro D, Crowly V, Cunningham CJ (2009) Acute hemodynamic response to sleeping head-up at 6 inches in older inpatients. Clin Autonom Res [epub ahead of print]Google Scholar
  7. 7.
    Felker GM, Cuculich PS, Gheorghiade M (2006) The Valsalva maneuver: a bedside “biomarker” for heart failure. Am J Med 119:117–122PubMedCrossRefGoogle Scholar
  8. 8.
    Flack M (1921) The Milroy lectures on respiratory efficiency. Relation to health and disease. Lancet 2:637–641CrossRefGoogle Scholar
  9. 9.
    Glasziou P, Chalmers I, Rawlins M, McCulloch P (2007) Analysis. When are randomized trials unnecessary ? Picking signal from noise. Br Med J 333:349–351CrossRefGoogle Scholar
  10. 10.
    Jordan J, Shannon JR, Black BK, Ali Y, Farley M, Costa F, Diedrich A, Robertson RM, Biaggioni I, Robertson D (2000) The pressor response to water drinking in humans: a sympathetic reflex? Circulation 101:504–509PubMedGoogle Scholar
  11. 11.
    MacLean AR, Allen EV (1940) Orthostatic hypotension and orthostatic tachycardia; treatment with the “head-up” bed. J Am Med Ass 115:2162–2167Google Scholar
  12. 12.
    MacLean AR, Allen EV, Magath TB (1944) Orthostatic tachycardia and orthostatic hypotension: defects in the return of venous blood to the heart. Am Heart J 27:145–163CrossRefGoogle Scholar
  13. 13.
    Mann S, Altman DG, Raftery EB, Bannister R (1983) Circadian variation of blood pressure in autonomic failure. Circulation 68:477–483PubMedGoogle Scholar
  14. 14.
    Mathias CJ, Fosbraey P, da Costa PF, Thornley A, Bannister R (1986) The effect of desmopressin on nocturnal polyuria, overnight weight loss, and morning postural hypotension in patients with autonomic failure. Br Med J 293:353–354CrossRefGoogle Scholar
  15. 15.
    Mineda Y, Sumiyoshi M, Yasuda M, Nakasato K, Nakasato Y, Nakato Y, Yamachuchi H (2000) Circadian variation of vasovagal syncope. J Cardiovasc Electrophysiol 11:1078–1080PubMedCrossRefGoogle Scholar
  16. 16.
    Omboni S, Smit AA, Lieshout JJv, Settels JJ, Langewouters GJ, Wieling W (2001) Mechanisms underlying the impairment in orthostatic tolerance after nocturnal recumbency in patients with autonomic failure. Clin Sci 101:619–620CrossRefGoogle Scholar
  17. 17.
    Ooi WL, Hossain M, Lipsitz LA (2000) The association between orthostatic hypotension and recurrent falls in nursing home residents. Am J Med 108:106–111PubMedCrossRefGoogle Scholar
  18. 18.
    Penston J (2005) Large-scale randomised trials—a misguided approach to clinical research. Med Hypotheses 64:651–657PubMedCrossRefGoogle Scholar
  19. 19.
    Planck M (1932) Where is science going? Prologue by Albert Einstein. Translation and biographical note by James Murphy. W. W. Norton and Co, New YorkGoogle Scholar
  20. 20.
    Raj SR, Garland EM, Biaggioni I, Black I, Robertson D (2005) Morning heart rate surge in postural tachycardia syndrome. Circulation 112:U810CrossRefGoogle Scholar
  21. 21.
    Raj SR, Biaggioni I, Black I, Robertson D (2008) Understanding the variability of standing heart rate in the postural tachycardia syndrome. Diurnal rhythms versus placebo effect. Heart Rhythm 5(5S):S129–S130Google Scholar
  22. 22.
    Sato K, Biaggioni I, Raj SR, Robertson D, Diedrich A (2008) Diminished diurnal variations of blood pressure in postural tachycardia syndrome. Clin Auton Res 18:250Google Scholar
  23. 23.
    Singer W, Opfer-Gehring TL, McPhee BR, Hilz MJ, Low PA (2001) Influence of posture on the Valsalva manoeuvre. Clin Sci 100:430–433CrossRefGoogle Scholar
  24. 24.
    Supanaranond W, Davis TME, Pukrittayakamee S, Nagachinta B, White NJ (1993) Abnormal circulatory control in falciparum malaria: the effects of antimalarial drugs. Eur J Clin Pharmacol 44:325–329PubMedCrossRefGoogle Scholar
  25. 25.
    Swales JD (1999) Evidence-based medicine and hypertension. J Hypertens 17:1511–1516PubMedCrossRefGoogle Scholar
  26. 26.
    Ten Harkel ADJ, van Lieshout JJ, van Lieshout EJ, Wieling W (1990) The assessment of cardiovascular reflexes; influence of posture and period of preceding test. J Appl Physiol 68:147–153PubMedGoogle Scholar
  27. 27.
    Ten Harkel ADJ, Van Lieshout JJ, Wieling W (1992) Treatment of orthostatic hypotension with sleeping in the head-up tilt position, alone and in combination with fludrocortisone. J Intern Med 232:139–145PubMedGoogle Scholar
  28. 28.
    Thijs AD, Wieling W, Van den Aardweg JG, van Dijk JG (2007) Respiratory countermaneuvers in autonomic failure. Neurology 69:582–585PubMedCrossRefGoogle Scholar
  29. 29.
    Vandenbroucke JP (1999) Case reports in an evidence-based world. J R Soc Med 92:159–163PubMedGoogle Scholar
  30. 30.
    Vandenbroucke JP (2008) Observational research, randomized trials, and two views of medical science. Plos Med 5:339–343CrossRefGoogle Scholar
  31. 31.
    van Dijk N, Boer MC, De Santo T, Grovale N, Aerts AJ, Boersma L, Wieling W (2007) Daily, weekly, monthly, and seasonal patterns in the occurrence of vasovagal syncope in an older population. Europace 9:823–828CrossRefGoogle Scholar
  32. 32.
    Van Lieshout JJ, Ten Harkel ADJ, Van Leeuwen AM, Wieling W (1991) Contrasting effects of acute and chronic volume expansion on orthostatic blood pressure control in a patient with autonomic circulatory failure. Neth J Med 39:72–83PubMedGoogle Scholar
  33. 33.
    Van Lieshout JJ, ten Harkel ADJ (1992) Wieling. Combating orthostatic dizziness in autonomic failure by physical maneuvers. Lancet 339:897–898PubMedCrossRefGoogle Scholar
  34. 34.
    Van Lieshout JJ, Ten Harkel ADJ, Wieling W (2000) Fludrocortisone and sleeping in the head-up position limit the postural decrease in cardiac output in autonomic failure. Clin Auton Res 10:35–421PubMedCrossRefGoogle Scholar
  35. 35.
    Vogel ER, Corfits JL, Sandroni P, Sletten DM, Bennaroch EE, Fealy RD, Suarez G, Gehring TL, Jade A, Low PA (2008) Effect of position on Valsalva maneuver: supine versus 20 degree position. J Clin Neurophysiol 25:313–316PubMedCrossRefGoogle Scholar
  36. 36.
    Weiss A, Chagnac A, Beloosesky Y, Weinstein T, Grinblat J, Grossman E (2004) Orthostatic hypotension in the elderly: are the diagnostic criteria adequate? J Hum Hypertens 18:310–315CrossRefGoogle Scholar
  37. 37.
    Wieling W, van Lieshout JJ, Hainsworth RW (2002) Extracellular fluid volume expansion in patients with posturally related syncope. Clin Auton Res 12:242–249PubMedCrossRefGoogle Scholar
  38. 38.
    Wieling W, Karemaker JM (2008) Recording of heart rate and blood pressure in the evaluation of neuro-cardiovascular control. In: Mathias CJ, Bannister R (eds) Autonomic failure. A textbook of clinical disorders of the autonomic nervous system, 4th edn. Oxford University Press, Oxford (in press)Google Scholar
  39. 39.
    Wilcox CS, Puritz R, Lightman SL, Bannister R, Aminoff MJ (1984) Plasma volume regulation in patients with progressive autonomic failure during changes in salt intake or posture. J Lab Clin Med 1:331–339Google Scholar

Copyright information

© Steinkopff Verlag Darmstadt 2009

Authors and Affiliations

  • Wouter Wieling
    • 1
  • S. R. Raj
    • 2
  • R. D. Thijs
    • 3
    • 4
  1. 1.Dept. of Internal Medicine, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
  2. 2.Autonomic Dysfunction Centre, Division of Clinical Pharmacology, Dept. of Medicine and PharmacologyVanderbilt UniversityNashvilleUSA
  3. 3.Epilepsy Institute of the Netherlands SEINHeemstedeThe Netherlands
  4. 4.Dept. of NeurologyLeiden University Medical CentreLeidenThe Netherlands

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