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Orthostatic Hypotension
Aka: Orthostatic Hypotension, Postural Hypotension, Orthostatic Blood Pressure, Orthostasis, Orthostatic Syncope, Postural Blood Pressure, Postural Pulse
- See Also
- Medication Causes of Orthostatic Hypotension
- Dizziness
- 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
- 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
- McGee (1999) JAMA 281(11): 1022-9 [PubMed]
- Johnson (1995) Acad Emerg Med 2(8):692-7 [PubMed]
- Orthostasis is present in as many as 20-50% of those over age 65 years (and typically asymptomatic)
- Rutan (1992) Hypertension 19(6 pt 1): 508-19 [PubMed]
- Ooi (1997) jAMA 277(16):1299-304 [PubMed]
- 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
- Symptoms
- Dizziness or light headedness on standing
- Causes
- Medications
- See Medication Causes of Orthostatic Hypotension
- Cardiogenic
- Myocardial Infarction
- Arrhythmia
- Aortic Stenosis
- Myocarditis
- Pericarditis
- Bradycardia
- 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
- Cardioinhibitory Syncope
- Vasodepressor Syncope
- Venous pooling
- Postprandial Hypotension (occurs within 75 minutes of a meal)
- Large leg Varices
- Prolonged bed rest
- Strenuous Exercise
- Fever
- Sepsis
- Heat exposure
- Alcohol
- Miscellaneous causes
- Aging (may be normal over age 70 years)
- Hypokalemia
- Labs
- Basic chemistry panel (Electrolytes, Renal Function tests, Serum Glucose)
- Complete Blood Count
- Serum Vitamin B12
- Electrocardiogram
- Consider morning cortisol level
- Consider Holter Monitor
- Imaging
- Head CT or Head MRI
- Echocardiogram
- 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
- Evaluation
- See Head-Up Tilt Table Test
- Consider intravascular volume replacement (IV Fluids)
- Consider causes above (including medications)
- Complications
- Orthostatic Syncope
- 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)
- 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)
- References
- (2017) Presc Lett 24(2): 10
- Engstrom (1997) Am Fam Physician 56(5):1378-84 [PubMed]
- Lanier (2011) Am Fam Physician 84(5): 527-36 [PubMed]
- Low (2015) J Clin Neurol 11(3):220-6 +PMID:26174784 [PubMed]
- Mathias (1995) Neurology 45:S6-11 [PubMed]