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Introduction We have recently reported the high number of patients with joint hypermobility (JH) due to Ehlers Danlos Syndrome-hypermobile or Hypermobility Spectrum Disorder attending a dedicated syncope clinic with orthostatic intolerance and symptoms consistent with postural orthostatic tachycardia syndrome (POTS).1 Many patients had been seen repeatedly in primary and secondary care and had undergone echocardiography and Holter monitoring, but few had received a clear diagnosis or management advice. We adopted a policy of routine joint assessment by Beighton scoring and tilt testing whenever possible in order to clarify the diagnosis and aid management. We have evaluated the diagnostic utility of tilt-table testing with a focus on the frequency and nature of autonomic abnormalities and their implications for patient care.Methods We conducted a retrospective analysis of patients with JH (Beighton score >4) attending a dedicated syncope clinic in a UK teaching hospital between 2021–2024. All patients underwent standardised clinical assessment and cardiac investigations including ECG, ambulatory Holter monitoring, echocardiography, and tilt-table testing using a 40-minute protocol without drug provocation. Tilt responses were categorised as orthostatic hypotension (initial, classical or delayed), reflex syncope, POTS (≥30 bpm rise in the first 10 minutes with symptoms), or abnormal heart rate responses below the POTS threshold. Clinical outcomes and treatment direction following diagnostic clarification were recorded.Results A total of 218 patients with JH attended the syncope clinic, made up predominantly of young females (median age 24 years). The most common presenting symptom was dizziness on standing (77%), followed by syncope (10%) and palpitations (10%). Non-cardiovascular symptoms including chronic pain, fatigue and gastrointestinal symptoms and migraine were common. All underwent a standard set of investigations, including 162 (74%) that completed tilt-table testing. Tilt-table testing demonstrated abnormalities in the majority (82%). Initial orthostatic hypotension was the most frequent finding, followed by classical or delayed orthostatic hypotension and reflex syncope patterns. Only a minority (10%) fulfilled the strict >30 bpm increase within 10 minutes of tilt criterion for POTS, while 15% showed a heart rate increase of > 20 bpm. In many cases, the resting heart rate was elevated (> 90 bpm in 47% and > 100 bpm in 26%) with only a modest increase with tilt.Tilt results had clear management implications. Postural hypotension patterns directed therapy towards salt loading, fluid augmentation, and fludrocortisone or midodrine in selected cases. Tachycardic phenotypes prompted consideration of ivabradine, or low-dose beta-blockers. Across the cohort, conservative management benefitted over half of patients. Most who required pharmacological therapy reported symptomatic improvement.Conclusions In a syncope clinic population with JH and orthostatic intolerance, tilt-table testing demonstrated a substantial diagnostic yield and provided actionable classifications of orthostatic intolerance that were not apparent on routine cardiac investigations.We suggest that the conventional ‘>30 bpm increase’ criterion for POTS on tilt or active stand will misclassify many patients leading to under-recognition of POTS and failure to commence appropriate treatment. Such arbitrary dichotomisation of patients into POTS or not POTS based on heart rate responses to tilt has no clear biological basis. POTS may be better viewed as a ‘symptom cluster’ consisting of dizziness and rapid palpitations on standing or minor exertion which is usually accompanied by an abnormal tilt test.These findings support the value of tilt-table testing in confirming abnormal heart rate and BP control in patients with POTS due to JH syndromes.Routine incorporation of joint assessment and tilt-table testing within syncope pathways will expedite diagnosis, reduce unnecessary investigations, and improve directed treatment. Greater awareness of autonomic phenotypes in JH is needed, especially among acute physicians and cardiologists where scepticism remains common.Reference Abu Orabi Z, Thompson SE, van Vliet J, Gee K, Roy A, Townend JN. Joint hypermobility: an under-recognised cause of palpitations, dizziness, and syncope in young females. J Clin Med. 2025;14(20):7373.