The Schellong test: detecting orthostatic blood pressure and heart rate changes in German-speaking countries
KeywordsSchellong test Standing test Orthostatic hypotension Head-up tilt test Syncope
“Schellong test” is the eponym used in German-speaking countries to refer to the active standing test for measuring blood pressure and heart rate changes under gravitational stress. The test is named after Fritz Schellong, a European pioneer of cardiovascular autonomic neuroscience.
Blood pressure and heart rate measurements in the supine position, at 1-min intervals after standing up, and at 1-min intervals after lying down again
Blood pressure and heart rate measurements immediately after climbing up a staircase and at 1-min intervals afterwards
Measurement of the QRS complex duration on an ECG tracing prior to climbing the stairs in part (2), immediately afterwards, and at 1-min intervals afterwards
Schellong considered the responses in part (1) to depend on neurogenic regulation of peripheral blood vessels, part (2) on both neurogenic control of blood vessels and cardio-circulatory regulation, and part (3) on cardiac regulation only.
After studying the orthostatic blood pressure responses in 92 healthy subjects, he concluded: “As far as the responses in the upright position is concerned, we came to the conclusion that the systolic blood pressure behaves somewhat differently: it can rise a little or remain the same, or sink a little. A decrease of 5 or 10 mmHg is meaningless, but a decrease of 15 mm is the ‘borderline case’…the diastolic blood pressure usually increases by a few millimetres (5–10 mmHg), sometimes it remains the same, only in a few cases it drops slightly, but increases again while standing. The pulse rate shows an increase of 10–20, even 40 beats per minute. In young people the increase is greater than in older people; in the latter the frequency can also remain the same” .
By applying the simple methodology described above, Schellong already understood that orthostatic systolic blood pressure reductions greater than 20 mmHg are abnormal in the clinical setting , that diastolic blood pressure probably contributes to a lesser extent to orthostatic blood pressure regulation and its disorders , and that, above all, aging significantly affects baroreflex function [2, 13].
Nowadays there are much more sophisticated ways to examine both cardiac intrinsic and baroreflex function, but a simplified version of the Schellong, or standing test, i.e. the evaluation of heart rate and blood pressure changes from the supine to upright position, is still recommended as a bedside screening measure in patients with suspected cardiovascular autonomic dysfunction, including syncope, whenever the patient's clinical condition allows it [3, 18].
There is no universal standardized protocol for performing a standing test, although this usually consists of a supine phase of 5–10 min, followed by an active standing phase of at least 3 min, ideally 5–10 min. Blood pressure and heart rate are measured at the end of the supine phase and at 1-min intervals during the orthostatic challenge. If the patient is unable to stand up from the supine position, a sitting-to-standing protocol is acceptable , although less sensitive than the supine-to-standing one .
For screening purposes and when no other technologies are available, heart rate can be measured manually or with a pulse oximeter, while blood pressure can be obtained with an arm cuff .
A sustained blood pressure fall of at least 20 mmHg in systolic or at least 10 mmHg in diastolic or an absolute systolic blood pressure below 90 mmHg after 3 min standing qualifies for orthostatic hypotension [3, 10].
Orthostatic hypotension may be symptomatic, i.e., causing symptoms of organ hypoperfusion such as dizziness, cognitive slowness, blurred vision, or shoulder or neck pain; or asymptomatic, mostly depending on the lowest blood pressure value when standing . In the clinical setting, the most frequent causes of orthostatic hypotension are non-neurogenic, i.e., volume depletion (dehydration, blood loss) and medication side effects. In non-neurogenic orthostatic hypotension, baroreflex function is preserved, and the fall in blood pressure is compensated by a marked rise in heart rate. In contrast, when orthostatic hypotension is caused by neurodegenerative, metabolic, autoimmune, or genetic disorders affecting afferent or efferent autonomic pathways, baroreflex dysfunction is evident, and the orthostatic heart rate response to hypotension is reduced or absent . Evaluating the supine-to-standing heart rate changes may thus provide invaluable information about the cause of the orthostatic hypotension, and inform treatment.
Blood pressure measurements in the supine position may also detect supine hypertension , defined as blood pressure ≥ 140/90 mmHg at the end of a supine phase of at least 5 min in patients with neurogenic orthostatic hypotension. Neurogenic supine hypertension affects about 50% of patients with neurogenic orthostatic hypotension  and, if present, has major therapeutic and prognostic implications.
The active standing test may also detect delayed orthostatic hypotension, i.e., occurring beyond 3 min of orthostatic challenge , although prolonging the test to 10 min or more may be uncomfortable for geriatric patients. In this case a tilt-table test may be preferable.
There is conflicting evidence in the literature as to whether a standing or a head-up tilt test, i.e. an active or passive orthostatic challenge, is more sensitive for detecting orthostatic hypotension [1, 12]: these tests are eventually to be considered of complementary value in the diagnostic workup of orthostatic hypotension.
Continuous heart rate and blood pressure monitoring during a standing test may also identify transient orthostatic blood pressure changes, such as initial orthostatic hypotension (i.e. a BP fall > 40/20 mmHg within the first 15 s upon standing, with recovery within 30 s) or delayed blood pressure recovery (i.e. a BP fall > 20/10 mmHg persisting 30 s after standing) , which have recently been acknowledged as possible causes of falls and syncope in the aging population [8, 16].
A standing test may be also used to screen for postural tachycardia syndrome (POTS). In case of suspected vasovagal syncope extended continuous heart rate and blood pressure monitoring for up to 45 min at 60-degrees head-up tilt is often necessary, in order to diagnose and classify syncope . The sensitivity is indeed higher during a head-up tilt examination, thanks to the exclusion of the muscular leg pump, to the possibility of prolonging the test beyond 10 min or adding provocations like sublingual nitro-glycerine or isoproterenol .
Bernard of Chartres, a twelfth-century philosopher, said that “we, the Moderns, are like dwarves perched on the shoulders of giants, the Ancients, and thus we are able to see more and farther than the latter. And this is not at all because of the acuteness of our sight or the stature of our body, but because we are carried aloft and elevated by the magnitude of the giants.” Thanks to advanced technology, modern clinical autonomic medicine is nowadays able to diagnose, quantify, and monitor over time a wide range of cardiovascular autonomic disorders. More than 80 years ago, however, Schellong already understood the key point of cardiovascular autonomic testing: to stress the baroreflex by standing up.
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Conflict of interest
The authors declare no conflicts of interest.
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