II. Definition: Orthostasis
- Measurement
- Occurs within 3 minutes of standing
- Orthostatic Blood Pressure
- Blood Pressure drop on standing of >20 mmHg systolic or 10 mHg diastolic
- Orthostatic Heart Rate
- Heart Rate increase on standing of 30 beats per minute
III. Efficacy
- Orthostatic Vital Signs have low utility and other measures should be used to assess volume status
- Swaminathan In Herbert (2013) EM: Rap 13(11): 6-7
- Orthostatic Blood Pressure and pulse are poor indicators of hypovolemia in Hemorrhage and dehydration
- Orthostasis is present in as many as 20-50% of those over age 65 years (and typically asymptomatic)
IV. Physiology
- Event: Rising from lying to standing position
- 300 to 800 ml of blood pools in legs
- Physiologic response
- Lower extremity Muscle contraction compresses veins
- Autonomic response
- Baroreceptors in aorta and carotids sense BP change
- Sympathetic Nervous System response
- Increases vascular tone
- Increases Heart Rate and cardiac contractility
V. Symptoms
- Dizziness or light headedness on standing
VI. Causes
- Medications
- Cardiogenic
- Hypovolemia (Tachycardia present, most common)
- Dehydration
- Hemorrhage
- Anemia
- Burn Injury
- Adrenal Insufficiency
- Diabetes Insipidus
- Straining
- Heavy lifting
- Urinating (Micturition Syncope)
- Neurogenic Causes
- Diabetic Neuropathy
- Spinal cord injury
- Guillain-Barre Syndrome
- Parkinsonism
- Tabes Dorsalis
- Amyloidosis
- Alcohol Abuse
- Vitamin B12 Deficiency (Pernicious Anemia)
- Syringomyelia
- Post-sympathectomy
- Human Immunodeficiency Virus (HIV)
- Idiopathic Orthostatic Hypotension
- Shy-Drager Syndrome
- Carotid Sinus Hypersensitivity
- Venous pooling
- Miscellaneous causes
- Aging (may be normal over age 70 years)
- Hypokalemia
VII. Labs
- Basic chemistry panel (Electrolytes, Renal Function tests, Serum Glucose)
- Complete Blood Count
- Serum Vitamin B12
- Electrocardiogram
- Consider morning cortisol level
- Consider Holter Monitor
VIII. Imaging
IX. Diagnosis
- See Head-Up Tilt Table Test
- Orthostatic Blood Pressure and Pulse
- Supine Blood Pressure, pulse after 3 minutes
- Standing Blood Pressure, pulse after 3 minutes
- Abnormal if Blood Pressure drops >20 systolic or 10 diastolic
- Response to 15 second Valsalva Maneuver
- Normally pressure falls, then rises over baseline
- Abnormal if pressure does not overshoot baseline
-
Pulse variation on deep breathing (sinus Arrhythmia)
- Normal response
- Tachycardia on inspiration
- Bradycardia on expiration
- Abnormal if <9 beat/min difference during cycle
- Normal response
X. Evaluation
- See Head-Up Tilt Table Test
- Consider intravascular volume replacement (IV Fluids)
- Consider causes above (including medications)
XI. Complications
- Orthostatic Syncope
XII. Management
- Avoid medications related to Orthostasis
- See Medication Causes of Orthostatic Hypotension
- Decrease dose or change medication to one less likey to cause Orthostatic Hypotension
- Consider stopping Tricyclic Antidepressants, Antipsychotics
- Modify diet
- Increase salt
- Indicated for 24 hour urinary Sodium <170 mmol Sodium in 24 hours
- Supplement up to 1-2 grams extra-per day (avoid in CHF, Edematous States)
- Increase water intake (>64 ounces daily)
- Avoid Alcohol
- Eat smaller, more frequent meals (avoid large carbohydrate rich meals)
- Increase salt
- Modify activity
- Avoid heat exposure or strenuous Exercise
- Sleep with head of bed slightly elevated
- Rise from bed slowly allowing for equilibration
- Avoid standing for long periods of time
- Isometric Exercises to work arms, legs and abdominal muscles (e.g. toe raises, thigh contractions, forward flexion at waist)
- While standing, move frequently and stand with crossed legs (consider leaning forward)
- Avoid work with arms above Shoulder height
- Dorsiflex feet several times before standing
- Consider Compression Stockings
- Consider medication therapy (esp. for neurologic causes)
- Review precautions before using
- Fludrocortisone (Florinef)
- Increases Sodium and water retention
- Precaution: Monitor for Hypokalemia
- Start at 0.1 mg daily, titrate weekly by 0.1 mg to maximum of 1mg daily
- Target
- Improved symptoms
- Significant Edema
- Weight gain > 3.6 kg
- Midodrine (ProAmitine)
- Limit to specialist use (FDA recommends removing from market due to lack efficacy)
- Risk of supine Hypertension (mediction should be taken before 6 pm)
- Increases Blood Pressure for 2-3 hours
- Contraindicated in Coronary Artery Disease, Hyperthyroidism, Acute Renal Failure
- Start at 2.5 three times daily, titrate weekly by 2.5 mg to maximum dose of 10 mg three times daily
- Pyridostigmine (Mestinon)
- Start at 30 mg bid to tid and titrate to symptom control or 60 mg three times daily
- Erythropoietin has been used if comorbid Anemia
- Northera (droxidopa)
- Very expensive ($7800/month) compared to other agents listed above (e.g. Fludrocortisone is $35/month)
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Related Studies
Definition (MSHCZE) | Pokles tlaku krve objevující se při přechodu do vzpřímené polohy. Může způsobit přechodnou poruchu prokrvení mozku s krátkým bezvědomím (synkopou) nebo pocitem závrati či nejistoty. Příč. nervové poruchy např. diabetická neuropatie, některé léky např. některá antihypertenziva, značná ztráta krve, selhání nadledvin, dlouhodobý pobyt na lůžku aj. Prevencí při těchto stavech je opatrné a postupné vstávání. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
Definition (NCI) | Sudden fall of the blood pressure of at least 20/10 mm Hg when a person stands up. |
Definition (CSP) | fall in blood pressure associated with dizziness, syncope and blurred vision occurring upon standing or when standing motionless in a fixed position. |
Definition (MSH) | A significant drop in BLOOD PRESSURE after assuming a standing position. Orthostatic hypotension is a finding, and defined as a 20-mm Hg decrease in systolic pressure or a 10-mm Hg decrease in diastolic pressure 3 minutes after the person has risen from supine to standing. Symptoms generally include DIZZINESS, blurred vision, and SYNCOPE. |
Concepts | Finding (T033) |
MSH | D007024 |
ICD9 | 458.0 |
ICD10 | I95.1 |
SnomedCT | 155488005, 28651003 |
English | Hypotension, Postural, HYPOTENSION ORTHOSTATIC, HYPOTENSION POSTURAL, Orthostatic hypo-tension, Hypotension, Orthostatic, Orthostatic Hypotension, orthostatic hypotension, orthostatic hypotension (physical finding), orthostatic hypotension (diagnosis), orthostatic hypotension was observed, Hypotension orthostatic, Hypotension postural, HYPOTENSION, ORTHOSTATIC, Postural Hypotension, Hypotension, postural, Hypotension, Orthostatic [Disease/Finding], hypotension postural, Hypotension;orthostatic, Hypotension;postural, hypotension orthostatic, Orthostatic hypotension, Postural hypotension, Orthostatic hypotension (disorder), hypotension; orthostatic, hypotension; postural, orthostatic; hypotension, postural; hypotension, Hypotension, orthostatic, postural hypotension |
French | HYPOTENSION ORTHOSTATIQUE, Hypotension orthostatique, Hypotension posturale |
Portuguese | HIPOTENSAO ORTOSTATICA, HIPOTENSAO POSTURAL, Hipotensão ortostática, Hipotensão Ortostática, Hipotensão Postural |
Spanish | HIPOTENSION ORTOSTATICA, HIPOTENSION POSTURAL, Hipotensión postural, hipotensión arterial ortostática (trastorno), hipotensión arterial ortostática, hipotensión arterial postural, Hipotensión ortostática, Hipotensión Ortostática, Hipotensión Postural |
Dutch | orthostatische hypotensie, houdingsafhankelijke hypotensie, hypotensie houdingsafhankelijk, houdingsafhankelijk; hypotensie, hypotensie; houdingsafhankelijk, hypotensie; orthostatisch, orthostatisch; hypotensie, Orthostatische hypotensie, Hypotensie, orthostatische, Hypotensie, posturale |
German | lageabhaengige Hypotonie, Hypotonie lageabhaengig, HYPOTONIE LAGEABHAENGIG, HYPOTONIE ORTHOSTATISCH, Orthostatische Hypotonie, Orthostasesyndrom, Hypotonie, orthostatische, Positionshypotonie |
Swedish | Hypotoni, ortostatisk |
Japanese | キリツセイテイケツアツ, タイイセイテイケツアツ, 起立性低血圧, 低血圧-起立性, 体位性低血圧, 立ち眩み, 体位性低血圧症, 立ちくらみ, 起立性低血圧症 |
Finnish | Ortostaattinen hypotensio |
Russian | GIPOTENZIIA ORTOSTATICHESKAIA, GIPOTENZIIA POSTURAL'NAIA, ГИПОТЕНЗИЯ ОРТОСТАТИЧЕСКАЯ, ГИПОТЕНЗИЯ ПОСТУРАЛЬНАЯ |
Czech | Posturální hypotenze, Ortostatická hypotenze, Hypotenze ortostatická, hypotenze ortostatická, posturální hypotenze, ortostatická hypotenze |
Italian | Ipotensione posturale, Ipotensione ortostatica |
Korean | 기립성 저혈압 |
Polish | Niedociśnienie ortostatyczne, Hipotonia ortostatyczna |
Hungarian | Orthostatikus hipotenzió, Hypotensio orthostatica, Orthostatikus alacsony vérnyomás, Orthostatikus hypotensio |
Norwegian | Ortostatisk hypotensjon |
Ontology: Orthostasis (C0149746)
Concepts | Sign or Symptom (T184) |
MSH | D004244 |
Portuguese | Ortoestase |
Spanish | Ortostasis |
French | Orthostase |
German | Orthostase |
English | orthostasis, Orthostasis |
Italian | Ortostasi |
Norwegian | Blodtrykksfall i oppreist stillling, Ortostatisme |
Czech | závratě při napřímení, vzpřímený postoj, ortostatický pokles tlaku |
Dutch | Orthostasis |
Ontology: Syncope due to orthostatic hypotension (C2316624)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 432524006 |
English | Syncope due to orthostatic hypotension (disorder), Syncope due to orthostatic hypotension |
Spanish | síncope debido a hipotensión ortostática (trastorno), síncope debido a hipotensión ortostática |