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Clinical Effectiveness
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Postal Questionnaire survey: The use of sleeping with the head of bed tilted up in clinical practice for treatment of orthostatic hypotension, by Chie Wei Fan, D Coakley, J B Walsh and C J Cunningham (Falls and Syncope Service, Mercers Institute for Research into Ageing (MIRA), St James Hospital, Dublin), presented as a clinical effectiveness poster at the BGS Spring Meeting 2005

Treatment of orthostatic hypotension (OH) is problematic as existing treatments such as drinking fluids, salt replacement and medications may lead to hypertension. Older people tend to tolerate these interventions poorly [1] . Sleeping head up tilt (SHU) is a recognised treatment for OH with a small evidence base for angles of at least 12 degrees [2, 3, 4]. SHU is postulated to work through the renin-angiotensin-aldosterone system by reducing over night natriuresis and diuresis [5]. The aim of our study was to determine how SHU was prescribed in clinical practice.

We carried out a multi-country, cross-sectional mail survey of 193 delegates of an international conference on syncope in Newcastle, United Kingdom in November 2003. The conference provided a unique opportunity to sample the opinions of clinicians and physiologists who were experienced in this field. The structured questionnaire ascertained the country and position in the department of the respondents. The respondents were asked (i) if they routinely prescribed SHU, (ii) whether SHU was used first, (iii) the angles and the heights of elevation of the head of the bed and (iv) the reasons for not using SHU. Other modalities of treatment for OH were determined. Where the respondents gave specific heights of elevation, we calculated the corresponding angle of the tilt of bed based on the standard 75-inch bed.

There were 149 respondents representing a 67% response rate. One hundred and thirty five (91%) of the respondents were from the United Kingdom and 105 (70%) were either head of department or consultants. Ninety (60%) of the respondents prescribed SHU (40 [27%] routinely) and 66 specified an angle. These ranged from 20 to 450 with a median angle of elevation of 6.50. Of those who recommended specific tilt angles, 44 (67%) recommended tilt < 120 with 24 (36%) recommending 3-50 tilt. SHU ranked fifth in OH treatment modalities utilised. The treatment modalities for OH amongst the experts are summarised in table 1. The most common treatment prescribed was fludrocortisone. SHU ranked fifth after fludrocortisone, drinking water, physical counter manoeuvres and salt loading. The main reason for not using SHU was because the respondents did not believe in its effectiveness.

Table 1. Modalities for Treatment of OH from survey

Others include caffeine tablets, ephedrine and non-steroidal anti-inflammatory drugs

In conclusion, SHU was used routinely by a significant minority of syncope clinics. The majority of doctors prescribing this treatment were using an angle for which effectiveness has not been demonstrated. Further work into the effectiveness and tolerability of this intervention is required.

Chei Wei Fan

References

1. Hussain, R.M., et al., Fludrocortisone in the treatment of hypotensive disorders in the elderly. Heart, 1996. 76(6): p. 507-9.
2. MacLean, A.R. and E.V. Allen, Orthostatic hypotension andorthostatic tacchycardia:treatment with the ‘head-up’ bed. J Am Med Assoc, 1940. 115: p. 2162-7.
3. Ten Harkel, A.D., J.J. Van Lieshout, and W. Wieling, Treatment of orthostatic hypotension with sleeping in the head-up tilt position, alone and in combination with fludrocortisone. J Intern Med, 1992. 232(2): p. 139-45.
4. van Lieshout, J.J., A.D. ten Harkel, and W. Wieling, Fludrocortisone and sleeping in the head-up position limit the postural decrease in cardiac output in autonomic failure. Clin Auton Res, 2000. 10(1): p. 35-42.
5. Mathias, C.J. and R. Bannister, Management of postural hypotension, in Autonomic Failure: A textbook of Clinical disorders of the autonomic nervous systems., R. Bannister and C.J. Mathias, Editors. 2002, Oxford Medical Publications, Oxford: Oxford. p. 342-356.

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