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Aims: We applied near-infrared-spectroscopy (NIRS) to measure absolute frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients investigated for unexplained syncope.Methods and results: Synchronized non-invasive beat-to-beat haemodynamic monitoring, ECG, SctO2 (NIRS; normal range: 60-80%), and peripheral oxygen saturation (left hand, SpO2) were applied during HUT in a random sample of patients with unexplained syncope. Tracings of 54 patients (mean-age: 55 ± 19 years, 39% male) with negative HUT, vasovagal syncope (VVS), or orthostatic hypotension (OH) were analysed. In 44 patients HUT was diagnostic, in 10 HUT was negative. Thirty-one experienced VVS. Of these, 6 had spontaneous and 25 nitroglycerin-induced syncope. Thirteen patients had orthostatic hypotension (OH). Although there was no significant change in mean-arterial pressure from baseline to 1 min before syncope or end of passive HUT phase (-1.4 ± 13.9 mmHg; P = 0.45), there was a significant fall in SctO2 during the same period (-3.2 ± 3.2%; P ≤ 0.001). Among patients who experienced syncope, a decrease in SctO2 from 71 ± 5% at baseline to 53 ± 9% (P < 0.001) at syncope was observed. During HUT, there was a significant difference in delta SctO2 between spontaneous VVS (-4.5 ± 3.0%) and negative HUT (-1.3 ± 1.9%; P  = 0.021), but not between spontaneous VVS and OH (-5.4 ± 4.2%; P = 0.65). In spontaneous VVS, progressive decrease of SctO2 was independent of mean arterial pressure decrease (P  = 0.22).Conclusions: Progressive decrease in cerebral tissue oxygenation independent of mean-arterial pressure may precede spontaneous vasovagal reflex during tilt. Patients experience syncope when SctO2 falls below 60%. These data confirm clinical utility of absolute cerebral oximetry monitoring for syncope investigation. We applied NIRS to measure frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients with unexplained syncope. In 44 of 54 patients, HUT was diagnostic. In patients with syncope, a significant SctO2-decrease was observed. Different patterns of SctO2 can be detected. [ABSTRACT FROM AUTHOR]

Background: Orthostatic hypotension (OH) is an important differential diagnosis in unexplained syncope. Neurogenic OH (nOH) has been postulated to differ from non-neurogenic OH (non-nOH), yet pathophysiological differences are largely unexplored. We aimed to investigate etiology and tilt table test (TTT)-induced hemodynamic responses in symptomatic OH patients., Methods: We performed a retrospective study analyzing patients referred for unexplained syncope or highly symptomatic orthostatic intolerance with TTT-verified classical OH (cOH). Medical records were analyzed for the presumptive etiology of cOH. Fifty-two patients (mean age 73±9 years, 46% women) with good quality TTT recordings were divided into three groups on clinical grounds: nOH, non-nOH, and mixed OH. The log-ratio (LR) method was applied to compare the decrease in mean arterial pressure (MAPLR) and corresponding contributions of heart rate (HRLR), stroke volume (SVLR) and total peripheral resistance (TPRLR) during the upright phase of TTT., Results: The prevalence of cOH was 12 (23%) nOH, 14 (27%) non-nOH and 26 (50%) mixed OH. No difference in MAPLR was observed among the three groups during the 4th upright minute of TTT (nOH: -0.10±0.04 vs. non-nOH: -0.07±0.05 and vs. mixed OH: -0.06±0.05, p=0.10). The contributions of HRLR, SVLR and TPRLR to the drop in MAPLR did not differ between groups (all p>0.05)., Conclusions: One-half of highly symptomatic OH patients had mixed OH, whereas one-quarter had either pure neurogenic, or non-neurogenic OH, respectively. Different forms of OH were indifferentiable based on hemodynamic responses during TTT, questioning the clinical utility of such classification. Larger studies are needed to confirm these findings., (© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Postural orthostatic tachycardia syndrome (POTS) is a frequently diagnosed cardiovascular disorder after COVID-19 infection. POTS is characterized by the presence of excessive sinus tachycardia on standing without a fall in blood pressure (BP). We investigated the BP profile using 24-hour ambulatory BP monitoring in patients with new-onset POTS after COVID-19 compared with prepandemic population-based controls., Methods: We performed a case-control study in 100 patients (mean age, 40.0±12.9 years; 85% women) with verified post-COVID-19 new-onset POTS diagnosed by a positive head-up tilt testing versus 100 controls from a population-based cohort with a negative active standing test, no history of syncope, POTS, or endocrine disease (mean age, 42.3±14.0 years; 78% women). Twenty-four-hour BP profile was assessed for circadian BP variation including hypotensive systolic BP (SBP) episodes (<80, <90, and <100 mm Hg)., Results: Patients with post-COVID-19 POTS had significantly higher nighttime SBP, but not daytime SBP, and more daytime SBP hypotensive episodes compared with controls. Nondipping (34% versus 19%; P <0.001) and reverse dipping patterns (9% versus 0%; P <0.001) were more frequent in post-COVID-19 POTS. In the logistic regression, patients with post-COVID-19 POTS had significantly higher mean 24-hour SBP (odds ratio, 1.08 [95% CI, 1.04-1.11]; P <0.001) and nighttime SBP (odds ratio, 1.07 [95% CI, 1.04-1.10]; P <0.001), independent of age and sex., Conclusions: Patients with post-COVID-19 POTS demonstrate higher mean 24-hour and nighttime SBP and show disruptions of circadian BP rhythm regulation compared with population-based controls, as well as more daytime hypotensive episodes. Future studies are needed to test whether patients with post-COVID-19 POTS may benefit from tailored BP therapy., Competing Interests: None.

Background: There is a well-known comorbidity between chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) which is only partially explained by common risk factors. Markers of cardiovascular autonomic dysfunction (CVAD), such as orthostatic hypotension and increased resting heart rate, are strongly associated with CAD. The autonomic nervous system also innervates the airways, and several studies have shown an association between autonomic dysfunction and COPD. However, less is known about whether CVAD and impairment of respiratory capacity are related in the population. We thus aimed to assess the relationship between markers of subtle CVAD and lung function in middle-aged subjects., Methods: In this cross-sectional study, we analysed data from CVAD assessment (orthostatic blood pressure and heart rate measurements) and pulmonary function tests from 5886 individuals from the Swedish CArdioPulmonary bioImage Study (SCAPIS). Subjects were middle aged and randomly selected from the Swedish population. Linear regression models and ANOVA analyses were used to relate orthostatic blood pressure and resting heart rate to lung function parameters (forced vital capacity (FVC), forced expiratory volume in one second (FEV 1 ), FEV 1 /FVC-ratio, diffusion capacity for carbon monoxide (D LCO ), respiratory resistance at 5 Hz (R5), respiratory resistance at 20 Hz (R20), decrease in resistance from R5 to R20 (R5-R20), reactance in distal airways (X5), resonant frequency (Fres) and reactance area (AX))., Results: Increasing systolic orthostatic blood pressure, decreasing diastolic orthostatic blood pressure, and increased resting heart rate associated with lower FVC (all p < 0.001) and FEV 1 (p = 0.001; p = 0.005; p < 0.001, respectively) in models including age, sex and height. Apart from diastolic orthostatic blood pressure and FEV 1 , all relationships remained significant after adjustment for possible confounders. Increased resting heart rate was associated with reduced D LCO (p < 0.001)., Conclusions: Increasing systolic orthostatic blood pressure, decreasing diastolic orthostatic blood pressure, and increased resting heart rate are associated with lower lung function, after adjustments for age, sex and height. These finding indicates associations between signs of cardiovascular autonomic dysfunction and lower lung function in the general population. However, the observed differences in lung function were small and the clinical application is unclear., Competing Interests: Declarations. Ethics approval and consent to participate: SCAPIS and the data handling for the current study were approved by the ethics committee at Umeå University (Dnr 2010-228-31M; Dnr 2016-511-31M; Dnr 2017-14-31) and Lund University (Dnr 2016/1031). All study participants provided written informed consent. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Rationale: Knowledge regarding the prevalence and shared and unique characteristics of the restrictive spirometric pattern (RSP) and preserved ratio impaired spirometry (PRISm) is lacking for a general population investigated with post-bronchodilator spirometry and computed tomography of the lungs. Objectives: To investigate shared and unique features for RSP and PRISm. Methods: In the Swedish CArdioPulmonary bioImage Study (SCAPIS), a general population sample of 28,555 people aged 50-64 years (including 14,558 never-smokers) was assessed. The participants answered a questionnaire and underwent computed tomography of the lungs, post-bronchodilator spirometry, and coronary artery calcification score. Odds ratios with 95% confidence intervals (CIs) were calculated using adjusted logistic regression. RSP was defined as forced expiratory volume in 1 second (FEV 1 )/forced vital capacity (FVC) ≥0.70 and FVC <80%. PRISm was defined as FEV 1 /FVC ≥0.70 and FEV 1 <80%. A local reference equation was applied. Results: The prevalence of RSP and PRISm were 5.1% (95% CI, 4.9-5.4) and 5.1% (95% CI, 4.8-5.3), respectively, with similar values seen in never-smokers. For RSP and PRISm, shared features were current smoking, dyspnea, chronic bronchitis, rheumatic disease, diabetes, ischemic heart disease, bronchial wall thickening, interstitial lung abnormalities, and bronchiectasis. Emphysema was uniquely linked to PRISm (odds ratio, 1.69; 95% CI, 1.36-2.10) versus 1.10 (95% CI, 0.84-1.43) for RSP. Coronary artery calcification score ≥300 was related to PRISm, but not among never-smokers. Conclusions: PRISm and RSP have respiratory, cardiovascular, and metabolic conditions as shared features. Emphysema is only associated with PRISm. Coronary atherosclerosis may be associated with PRISm. Our results indicate that RSP and PRISm may share more features than not.

Objectives: To examine cardiovascular autonomic function in middle-aged people with long-term cervical and upper thoracic spinal cord injury (SCI) compared with the general population, and explore if the neurological level of injury (NLI) is related to cardiovascular autonomic function., Design: Population-based cross-sectional study with matched controls., Setting: Outpatient SCI unit in Southern Sweden., Participants: Twenty-five individuals (20% women, mean age 58 years and mean time since injury 28 years, NLI C2-T6, American Spinal Injury Association Impairment Scale A-C) from the Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment (SPICA). Matched controls were obtained from the population-based Swedish CArdioPulmonary bioImage Study (SCAPIS) at a ratio of 5:1., Interventions: Not applicable., Outcome Measures: 24 h electrocardiography and deep breathing tests. 24 h ambulatory blood pressure (BP) monitoring and orthostatic BP tests., Results: In individuals with SCI compared with controls, heart rate variability (24h mean SD of the normal-to-normal interval 112 ms vs 145 ms, P < 0.001) and diastolic orthostatic BP increase (2.0 and 9.4 mmHg, P < 0.001), were significantly lower, whereas BP variability was significantly higher (24h mean systolic SD BP 17.8 mmHg vs 15.7 mmHg, P = 0.029). Circadian patterns of heart rate variability and BP (lack of nocturnal dip) were significantly different among the individuals with SCI than controls. Higher NLI was significantly (P < 0.05) correlated with impairments to various cardiovascular autonomic function variables., Conclusions: This exploratory study indicates that cardiovascular autonomic function is impaired in middle-aged people with long-term cervical and upper thoracic SCI compared with the general non-SCI population, and more pronounced with a higher NLI. Future research is needed to understand the pathophysiological mechanisms underlying these impairments, and the prognostic significance for individuals with SCI., Trial Registration: ClinicalTrials.gov identifier: NCT03515122.

Background: The ankle-brachial index (ABI) is the ratio of the ankle and brachial systolic blood pressures. In the clinical setting, low ABI (< 0.9) is an indicator of peripheral atherosclerosis, while high ABI (> 1.4) is a sign of arterial stiffness and calcification. The purpose of the current study was to investigate the association between ABI and physical activity levels, measured by accelerometer., Methods: The Swedish CArdioPulmonary bioImage Study (SCAPIS) is a Swedish nationwide population-based cross-sectional cohort for the study of cardiovascular and pulmonary diseases, in which individuals aged 50-64 years were randomly invited from the general population. The study population with data on ABI, physical activity, and sedentary time based on accelerometry was 27,737. Differences between ABI categories and associations to sedentary behavior, moderate to vigorous physical activity (MVPA), and other metabolic characteristics were compared. ABI was categorized as low, ABI ≤ 0.9, borderline, ABI 0.91-0.99, normal, ABI 1.0-1.39, and high, ABI ≥ 1.4., Results: Prevalence of low ABI was higher in the most sedentary quartiles compared to the least sedentary (0.6% vs. 0.1%, p < 0.001). The most sedentary individuals also exhibited higher BMI, higher prevalence of diabetes and hypertension. The proportion of wake time spent in MVPA was lowest in those with low ABI (0.033 ± 0.004; p < 0.001) and highest in those with ABI > 1.4 (0.069 ± 0.001; p < 0.001) compared to those with normal ABI. Compared to normal ABI, the proportion of sedentary time was highest in those with low ABI (0.597 ± 0.012; p < 0.001) and lowest in those with ABI > 1.4 (0.534 ± 0.002; p = 0.004)., Conclusion: This population-based study shows that middle-aged individuals with ABI > 1.4 have the highest level of physical activity, while individuals with a lower ABI, especially those with ABI < 0.9, are less active and spend more time sedentary. Future studies are needed to understand the relationships between ABI, physical activity, and the risk of peripheral arterial and cardiovascular disease in the general population., (© 2024. The Author(s).)

Aims: The pathophysiology of orthostatic hypotension (OH), a common clinical condition, associated with adverse outcomes, is incompletely understood. We examined the relationship between OH and circulating endostatin, an endogenous angiogenesis inhibitor with antitumour effects proposed to be involved in blood pressure (BP) regulation., Methods and Results: We compared endostatin levels in 146 patients with OH and 150 controls. A commercial chemiluminescence sandwich immunoassay was used to measure circulating levels of endostatin. Linear and multivariate logistic regressions were conducted to test the association between endostatin and OH. Endostatin levels were significantly higher in OH patients (59 024 ± 2513 pg/mL) vs. controls (44 090 ± 1978pg/mL, P < 0.001). A positive linear correlation existed between endostatin and the magnitude of systolic BP decline upon standing ( P < 0.001). Using multivariate analysis, endostatin was associated with OH (adjusted odds ratio per 10% increase of endostatin in the whole study population = 1.264, 95% confidence interval 1.141-1.402), regardless of age, sex, prevalent cancer, and cardiovascular disease, as well as traditional cardiovascular risk factors., Conclusion: Circulating endostatin is elevated in patients with OH and may serve as a potential clinical marker of increased cardiovascular risk in patients with OH. Our findings call for external validation. Further research is warranted to clarify the underlying pathophysiological mechanisms., Competing Interests: Conflict of interest: A.F. received speaker and consultation fees from Medtronic Inc., Finapres Medical Systems, and Bristol Myers Squibb. The remaining authors report no conflict of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value., (© 2023 The Authors. Clinical Physiology and Functional Imaging published by John Wiley & Sons Ltd on behalf of Scandinavian Society of Clinical Physiology and Nuclear Medicine.)

Postural Orthostatic Tachycardia Syndrome (POTS) reflects an autonomic dysfunction, which can occur as a complication to COVID-19. Our aim was to examine gastrointestinal symptoms and gut microbiota composition in patients with POTS and post-acute COVID-19 syndrome (PACS), compared with controls. POTS patients (n = 27), PACS patients (n = 32) and controls (n = 39) delivered fecal samples and completed a 4-day food diary, irritable bowel syndrome-severity scoring system (IBS-SSS), and visual analog scale for IBS (VAS-IBS). A total of 98 DNA aliquots were sequenced to an average depth of 28.3 million (M) read pairs (Illumina 2 × 150 PE) per sample. Diversity and taxonomic levels of the microbiome, as well as functional abundances were calculated for POTS and PACS groups, then compared with controls. There were several differences in taxonomic composition between POTS and controls, whereas only the abundance of Ascomycota and Firmicutes differed between PACS and controls. The clinical variables total IBS-SSS, fatigue, and bloating and flatulence significantly correlated with multiple individual taxa abundances, alpha diversity, and functional abundances. We conclude that POTS, and to a less extent PACS, are associated with differences in gut microbiota composition in diversity and at several taxonomic levels. Clinical symptoms are correlated with both alpha diversity and taxonomic and functional abundances., (© 2024. The Author(s).)

Background: Previous studies have shown that the ratio between alveolar volume (V A ) and total lung capacity (TLC) reflects ventilation heterogeneity in subjects with chronic obstructive pulmonary disease (COPD). However, the ratio and its correlation to respiratory symptoms had to our knowledge not previously been investigated in subjects with mild chronic airflow obstruction or without airflow obstruction (normal ratio FEV 1 /VC). The purpose of this study was to investigate potential connection between V A /TLC and respiratory symptoms, smoking habits and lung function parameters in subjects with normal spirometry and with mild chronic airflow obstruction., Methods: We examined 450 subjects (82 non-smokers with normal spirometry, 298 subjects who smoked or had smoked earlier but had a normal spirometry and 70 subjects with chronical airflow obstruction) with routine lung function tests and a questionnaire regarding respiratory symptoms., Results: This study showed 31 out of 54 subjects with a low V A /TLC had a normal ratio FEV 1 /VC. Of these subjects, 58.1 % had respiratory symptoms, compared to the group with normal ratio for both V A /TLC and FEV 1/ VC where 35.8 % had respiratory symptoms (p-value 0.02)., Conclusion: This study has shown that within the group of subjects with a normal ratio FEV 1 /VC, those with a decreased ratio V A /TLC had a higher prevalence of respiratory symptoms compared to subjects with a normal V A /TLC ratio. These findings indicate that including the ratio V A /TLC in the evaluation of a pulmonary function test assessment might increase the possibility to identify subjects with early or at risk of lung disease., Competing Interests: Declaration of competing interest The authors declare the following financial interests/ personal relationships which may be considered as potential competing interests: P Wollmer reports a relationship with Chiesi Pharma that includes consulting or advisory. P Wollmer has patent issued to Method and device for pulmonary function measurement., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Gastrointestinal (GI) symptoms are common in postural orthostatic tachycardia syndrome (POTS). We aimed to explore the prevalence and severity of GI symptoms in POTS, and to investigate immunological factors, hemodynamic findings, and their possible association with GI symptoms in POTS. Forty-three patients (93% female, median age 30.6 (26.0-41.0) years), previously diagnosed with POTS and 74 healthy controls (78% female, median age 35.6 (28.8-41.7) years) were included. The participants completed a questionnaire including prevalence of GI symptoms, the irritable bowel syndrome severity scoring system (IBS-SSS), and visual analog scale for IBS (VAS-IBS). All POTS patients were previously examined by tilt test (2010-2021) and the vast majority with more recent active standing test (2017-2021), which included monitoring of heart rate (HR). ΔHR was calculated as difference between supine and upright position. Continuous variables from IBS-SSS and VAS-IBS were correlated to ΔHR. A microarray containing several autoantigens commonly targeted in systemic autoimmune disorders was used to assess prevalent autoantibodies in POTS and controls. Total IgE and S-tryptase were analyzed. GI symptoms were more prevalent and severe in POTS than in controls; nausea being the most prevalent (79.1% vs 4.9%, p < 0.001) and bloating and flatulence being the most severe (median 65 (25-88) vs 0 (0-14), p < 0.001). The median total IBS-SSS was 213 (135-319) in POTS vs 13 (0-54) in controls ( p < 0.001). Total IBS-SSS was associated with low psychological wellbeing (r = 0.539, p < 0.001) in POTS. ΔHR max correlated inversely with abdominal pain (r = -0.406, p = 0.007). After adjustments for psychological wellbeing, total IBS-SSS still associated inversely with ΔHR 10min (β: 4.748; 95% CI: -9.172 to -0.324; p = 0.036). Similar results were seen with active standing test. The prevalence of autoantibodies did not differ between POTS and controls (29.4% vs 33.3%, p = 0.803). There was no association between GI symptoms and autoantibody status. Total IgE and tryptase were elevated in a few cases. This study confirms the high prevalence of GI symptoms in POTS. More pronounced tachycardia upon tilt table testing seems to be inversely correlated with severity of chronic GI symptoms in POTS. This study did not support the hypothesis that POTS is associated with immunological factors., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Tufvesson, Hamrefors, Fedorowski, Hansson and Ohlsson.)

Reduced lung function is associated with cardiovascular mortality, but the relationships with atherosclerosis are unclear. The population-based Swedish CArdioPulmonary BioImage study measured lung function, emphysema, coronary CT angiography, coronary calcium, carotid plaques and ankle-brachial index in 29,593 men and women aged 50-64 years. The results were confirmed using 2-sample Mendelian randomization. Lower lung function and emphysema were associated with more atherosclerosis, but these relationships were attenuated after adjustment for cardiovascular risk factors. Lung function was not associated with coronary atherosclerosis in 14,524 never-smokers. No potentially causal effect of lung function on atherosclerosis, or vice versa, was found in the 2-sample Mendelian randomization analysis. Here we show that reduced lung function and atherosclerosis are correlated in the population, but probably not causally related. Assessing lung function in addition to conventional cardiovascular risk factors to gauge risk of subclinical atherosclerosis is probably not meaningful, but low lung function found by chance should alert for atherosclerosis., (© 2023. The Author(s).)

Whereas autonomic dysfunction and the metabolic syndrome are clinically associated, the relationships with the plasma metabolome is unknown. We explored the association between orthostatic blood pressure responses and 818 plasma metabolites in middle-aged subjects from the general population. We included 3803 out of 6251 subjects (mean age, 57 years; 52% women) from the Malmö sub-cohort of The Swedish CardioPulmonary bioImage Study with information on smoking habits, diabetes, antihypertensive drug treatment, anthropometrics, hemodynamic measurements and 818 plasma metabolites (mass-spectrometry). The associations between each metabolite and orthostatic systolic blood pressure responses were determined using multivariable linear regression analysis and p values were corrected using the Bonferroni method. Six amino acids, five vitamins, co-factors and carbohydrates, nine lipids and two xenobiotics were associated with orthostatic blood pressure after adjusting for age, gender and systolic blood pressure. After additional adjustments for BMI, diabetes, smoking and antihypertensive treatment, the association remained significant for six lipids, four amino acids and one xenobiotic. Twenty-two out of 818 plasma metabolites were associated with orthostatic blood pressure responses. Eleven metabolites, including lipids in the dihydrosphingomyelin and sphingosine pathways, were independently associated with orthostatic systolic blood pressure responses after additional adjustment for markers of cardio-metabolic disease., (© 2023. Springer Nature Limited.)