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Orthostatic Hypotension

Postural Hypotension

Orthostatic hypotension (OH) is a frequently reported condition that causes a sudden decrease ≥ 20mm Hg in systolic blood pressure or ≥10 mm Hg in diastolic blood pressure, within 3 minutes of standing up from a horizontal or sitting position. Orthostatic hypotension may be symptomatic or not, and the symptoms range from mild to significant. Orthostatic hypotension is otherwise known as postural hypotension, since a change of posture is responsible for the sudden-onset episode of decreased blood pressure.


Presentation

Orthostatic hypotension is defined as an episode of sudden blood pressure (BP) drop, in three or fewer minutes after assuming a standing position, when one was previously lying supine or sitting. In order for the episode to be substantiated as orthostatic hypotension, the BP decrease should amount to 20 mmHg or more in the systolic blood pressure or to 10 mmHg or more in the diastolic blood pressure. In some cases, both the systolic and diastolic blood pressure drop.

Some OH cases are asymptomatic and do remain undiagnosed. Symptomatic OH produces typical symptoms that vary in terms of severity. One of the most commonly reported symptoms is light-headedness and dizziness [1]. A 2014 study reported that 20% of the patients with orthostatic hypotension felt light-headed when standing up. Considerable weakness, nausea, blurred vision and disorientation are also frequently reported symptoms. Fainting is a manifestation of orthostatic hypotension that is significantly severer than the aforementioned ones, although it is less common. The clinical picture is completed by the onset of headaches, shoulder ache or neck pain and chest tightness or dyspnea, on some occasions [2]. The most debilitating effect that OH can exert on a patient is generalized seizures, which have been rarely described. Some individuals experience an aggravation of the symptoms following a heavy meal or physical exercise.

Orthostatic hypotension typically affects senior citizens, even though it is not uncommon amongst the younger population [3] [4] [5].

Falling
  • The 92 droxidopa patients reported 308 falls, and the 105 placebo patients reported 908 falls.[ncbi.nlm.nih.gov]
  • Falls were then recorded in monthly fall diaries for 12 months. Unexplained fallers (UFs) were those who reported falls due to a blackout, dizziness, feeling faint, or "found themselves suddenly on the ground."[ncbi.nlm.nih.gov]
  • OH, defined according to standard criteria, affected 80% of the population and was not associated with falls. Conclusion: OH, defined according to 2011 criteria, is associated with falls and time to first fall.[ncbi.nlm.nih.gov]
  • BACKGROUND: One-third of older adults fall each year. Orthostatic hypotension (OH) has been hypothesized as an important risk factor for falls, but findings from prior studies have been inconsistent.[ncbi.nlm.nih.gov]
  • For IOH upon standing after supine rest, the hemodynamic mechanism can be either a large fall in CO or in SVR. For IOH upon arising from squatting a large fall in SVR is a consistent finding.[ncbi.nlm.nih.gov]
Fatigue
  • The patient is a 76 year-old woman who presented with progressive dizziness, anorexia, and fatigue. She had severe orthostatic hypotension (supine systolic blood pressure 186 mmHg and standing 79 mmHg).[ncbi.nlm.nih.gov]
  • Symptoms include light headedness, weakness, blurred vision, fatigue and lethargy and falls. Most patients have orthostatic hypotension due to non neurogenic causes.[ncbi.nlm.nih.gov]
  • Older age, comorbidities such as cardiac failure and kidney disease, being physically inactive at work, fatigue, self-reported dizziness in the past year, and the use of loop diuretics were found to be significantly associated with OH.[ncbi.nlm.nih.gov]
  • The patient has since returned to his routines of daily living and has reported no fatigue or other lingering adverse symptoms.[ncbi.nlm.nih.gov]
  • The most frequent symptoms of nOH were dizziness or lightheadedness, fatigue when standing, and difficulty walking. A negative impact on patient quality of life caused by nOH symptoms was reported by 59% of patients and 75% of caregivers.[ncbi.nlm.nih.gov]
Anemia
  • After administration of subcutaneous erythropoietin, his blood pressure drop in the upright position was decreased and symptoms disappeared unassociated with improvement of anemia.[ncbi.nlm.nih.gov]
  • The case of a patient who developed aseptic meningitis, hemolytic anemia, hepatitis, and orthostatic hypotension simultaneously during treatment with trimethoprim-sulfamethoxazole is described.[ncbi.nlm.nih.gov]
  • He also had underlying anemia. Ophthalmologic findings suggested bilateral anterior ischemic optic neuropathy (ION) as the cause of the visual loss.[ncbi.nlm.nih.gov]
  • […] electrophoresis fat-pad biopsy Diagnostic Test Details Treatment Options Acute all patients eliminate aggravating factors and institute lifestyle changes mineralocorticoid therapy and volume expansion short-acting pressors or droxidopa correction of anemia[online.epocrates.com]
  • A blood count or measurement of the concentration of red blood cells in the blood (hematocrit) should be done to rule out anemia.[njfaint.com]
Pallor
  • Throughout the procedure, assess her for signs and symptoms of hypotension, including dizziness, light-headedness, pallor, diaphoresis, or syncope (or arrhythmias if she's attached to a cardiac monitor).[journals.lww.com]
  • Report all findings to the treating medical provider, including all sets of blood pressure and pulse results, and whether the patient experienced pallor, diaphoresis, or faintness when upright.[ahrq.gov]
  • Their symptoms may include most of the symptoms of acute OI, plus: Nausea Neurocognitive deficits, such as attention problems Pallor Sensitivity to heat Sleep problems Other vasomotor symptoms. [1] Causes [ edit ] Symptoms of OI are triggered by the following[en.wikipedia.org]
  • This depends critically on the formation of ROS, [16] which also decreases NO, [134] often uncoupling nitric oxide synthase. [57] This mechanism occurs in a variant of "hyperadrenergic POTS" associated with tachycardia, pallor, vasoconstriction ("low[emedicine.com]
Fishing
  • We also investigated the associations with mercury exposure, a major source of which is fish, and which has been associated with higher CVD risk in KIHD.[ncbi.nlm.nih.gov]
Hypotension
  • Convert to ICD-10-CM : 458.0 converts directly to: 2015/16 ICD-10-CM I95.1 Orthostatic hypotension Approximate Synonyms Hypotension, orthostatic Orthostatic hypotension (low blood pressure upright) Syncope (fainting) due to orthostatic hypotension Syncope[icd9data.com]
  • The drop in blood pressure may be sudden (vasovagal orthostatic hypotension), within 3 minutes (classic orthostatic hypotension) or gradual (delayed orthostatic hypotension).[en.wikipedia.org]
  • Given the mounting evidence associating cardiovascular morbidity and mortality with orthostatic hypotension, cardiologists will play an increasing role in treating and managing patients with orthostatic hypotension.[ncbi.nlm.nih.gov]
  • BACKGROUND Postprandial hypotension, induced by an absorption of glucose from intestine, could be treated by acarbose; however, it was unclear whether dipeptidyl peptidase-4 inhibitor reduced postprandial hypotension.[ncbi.nlm.nih.gov]
  • Algorithm for the evaluation of orthostatic hypotension. Evaluation of Orthostatic Hypotension FIGURE 1. Algorithm for the evaluation of orthostatic hypotension.[aafp.org]
Chronic Hypotension
  • INTRODUCTION: Midlife hypertension is associated with dementia in longitudinal studies while chronic hypotension in the elderly is associated with dementia onset. Orthostatic hypotension could influence cognitive performance in the elderly.[ncbi.nlm.nih.gov]
  • Chronic hypotension: in the shadow of hypertension. Am J Hypertens. 1992 ; 5 :200S–205S. Crossref Medline Google Scholar 16 Ray Chaudhuri K, Maule S, Thomaides T, Pavitt D, Mathias CJ.[doi.org]
  • Chronic hypotension Primary acquired disease of the adrenals: Addison's disease (autoimmune adrenal failure). This is perhaps the best remembered cause of hypotension.[patient.info]
Hyperhidrosis
  • […] cerebral hypoperfusion Other Factors parkinsonian features cerebellar ataxia weight loss resting tachycardia or impaired heart rate variation abnormal GI motility erectile dysfunction and lack of ejaculation anhidrosis, heat intolerance, dry skin, focal hyperhidrosis[online.epocrates.com]
  • […] blackening and tunnel vision); syncope; hearing disturbances (including impaired hearing, crackles and tinnitus); pain in the neck (occipital/paracervical and shoulder region), low back pain or precordial pain; weakness, fatigue, lethargy; palpitations and hyperhidrosis[escardio.org]
Dizziness
  • AIMS: The aim of this study was to assess the involvement of the irregularity of the vertical perception in the dizzy elderly with OH. METHODS: This study consisted of 403 patients seeking treatment for dizziness in our hospital.[ncbi.nlm.nih.gov]
  • Objective: To compare early vs later OH measurements and their association with history of dizziness and longitudinal adverse outcomes.[ncbi.nlm.nih.gov]
  • The efficacy of droxidopa decreased gradually after 2 weeks, and its statistical significance was lost after 8 weeks (OHQ score MD -0.18, P 0.61; dizziness/lightheadedness score MD -0.71, P 0.11; and standing SBP MD 2.96, P 0.29).[ncbi.nlm.nih.gov]
  • Symptoms, which generally occur after sudden standing, include dizziness, lightheadedness, blurred vision, and syncope (temporary loss of consciousness).[ninds.nih.gov]
  • The most frequent symptoms of nOH were dizziness or lightheadedness, fatigue when standing, and difficulty walking. A negative impact on patient quality of life caused by nOH symptoms was reported by 59% of patients and 75% of caregivers.[ncbi.nlm.nih.gov]
Vertigo
  • The most common symptoms of orthostatic hypotension include weakness, lightheadedness, cognitive impairment, blurred vision, vertigo and tremulousness.[encyclopedia.com]
  • Twenty-seven of these 55 cases (i.e. 46%) were symptomatic, i.e. associated with at least one of the clinical symptoms of orthostatism (lightheadedness, general weakness, visual disturbance, dizziness, vertigo, malaise, falls, etc.).[pitt.edu]
  • Also see Vertigo. [1] M. Eigenbrodt et al [2] 沈漁﹐.精神病學,第3版,北京:人民衛生出版社,1994,11. Sponsors' Ads by Google 以下為谷歌 所提供之廣告[alternativehealing.org]
  • Some also report difficulty concentrating, blurred vision, tremulousness, vertigo, anxiety, palpitations (awareness of the heartbeat), unsteadiness, feeling sweaty or clammy, and sometimes nausea. A person may look pale.[en.wikipedia.org]
Altered Mental Status
  • Have severely altered mental status. Have possible spinal injuries. Have lower extremity or pelvic fractures. Are not mobile enough to get out of bed.[ahrq.gov]

Workup

The diagnosis of orthostatic hypotension is accurate, once blood pressure is measured in a patient who has been in a supine position for minimum 3 minutes, after standing up, as well as 3 and 5 minutes after they stand up. The last measurement is used to detect the extent to which blood pressure may drop upon standing but is not necessary for a decisive diagnosis [7]. Further tests are required in order to unveil the cause of the condition.

A detailed medical history is necessary, including symptoms elicited by OH, medications that the patient is taking and autonomic failure indications, such as severe constipation, incontinence, irregular sweating or tingling sensation of the feet. Physical examination may reveal dry skin and a neurological evaluation should be carried out to look for anything suggestive of Parkinson's disease.

Blood laboratory testing includes a complete blood count, ΗbA1c to diagnose diabetes, serum and urine protein electrophoresis, vitamin B12 and ANA autoantibodies. Plasma catecholamines are also measured, both in a standing and supine position; the measurement needs to take place when the patient is relaxed in a supine position and when they have stood up for at least 5 minutes.

Prolonged PR Interval
  • The most likely mechanism was an impaired cardiac filling with a short diastolic time due to a very prolonged PR interval, a somewhat "pseudo-pacemaker syndrome".[ncbi.nlm.nih.gov]
First-Degree Atrioventricular Block
  • There was a low incidence ( 2%) of cardiac AEs (eg, first-degree atrioventricular block, supraventricular extrasystoles).[ncbi.nlm.nih.gov]
2:1 Atrioventricular Block
  • We describe the case of an 81-year-old male patient with long PR interval and episodes of 2:1 atrioventricular block, in whom the implantation of a dual chamber pacemaker led to the disappearance of orthostatic hypotension.[ncbi.nlm.nih.gov]

Treatment

  • Paraneoplastic neuropathies associated with leukemia are rare, and early diagnosis and treatment are crucial due to the potential for irreversible neurological deficits and delay in treatment of the leukemia.[ncbi.nlm.nih.gov]
  • RESULTS: Orthostatic systolic and diastolic BP drops improved significantly at 3 months after treatment in all treatment groups.[ncbi.nlm.nih.gov]
  • It is the first drug to be licensed in the UK for the treatment of orthostatic hypotension. Here we consider the evidence for midodrine in the treatment of severe orthostatic hypotension and how it fits with current management strategies.[ncbi.nlm.nih.gov]
  • A report of two cases of orthostatic hypotension in acute tetraplegia that were resistant to classic treatment interventions. To discuss the use of midodrine hydrochloride for the treatment of orthostatic hypotension in early tetraplegia.[ncbi.nlm.nih.gov]
  • Treatment for recurrent vasovagal syncope includes increased salt and water intake and various drug treatments, most of which are still under investigation.[ncbi.nlm.nih.gov]

Prognosis

  • During the follow-up period, 22 patients (34.4%) had a poor prognosis, of which 8 (36.4%) had OH, which tended to be higher than those with a favorable prognosis.[ncbi.nlm.nih.gov]
  • Prognosis The prognosis for individuals with orthostatic hypotension depends on the underlying cause of the condition. x Prognosis The prognosis for individuals with orthostatic hypotension depends on the underlying cause of the condition.[ninds.nih.gov]
  • Our aim was to quantitatively evaluate the prevalence and risk factors of OH in patients with diabetes mellitus (DM) and assess its prognosis.[ncbi.nlm.nih.gov]
  • Given the poor prognosis of paraneoplastic autonomic dysfunction, it is important to accurately diagnose the cause of orthostatic hypotension occurring on a background of malignancy.[ncbi.nlm.nih.gov]
  • The prognosis of acute pan-dysautonomia is usually unsatisfactory, but the present patient showed good steroid-responsiveness probably because impaired preganglionic sympathetic myelinated fibers and medulla oblongata recovered quickly.[ncbi.nlm.nih.gov]

Etiology

  • View/Print Table TABLE 2 Clinical Clues to Non-Neurogenic Etiologies of Orthostatic Hypotension Findings on history and physical examination Possible etiology Chest pain, palpations, shortness of breath, rales, edema, arrhythmia, murmur Congestive heart[aafp.org]
  • FOLLOW UP: If a reversible etiology is identified, orthostatic blood pressure and pulse should be repeated once the etiology is corrected to assure improvement and that multiple etiologies were not contributing factors.[consultgeri.org]
  • This is the first report showing that midodrine has the potential to improve post-spaceflight orthostatic hypotension and suggesting that reduced venous return contributes to the etiology.[ncbi.nlm.nih.gov]
  • The patient's clinical features and positive tilt test only after nitroglycerine lead us to hypothesize that the arrhythmia plays a more important role in the etiology of symptoms with respect to autonomic impairment and that the pathophysiological mechanism[ncbi.nlm.nih.gov]
  • Main predisposing factors for OH are HF severity, non-ischemic HF etiology, prolonged bed rest, hypertension and polypharmacy. OH in HF is generally managed according to recommendations for treatment of OH in the non-HF population.[ncbi.nlm.nih.gov]

Epidemiology

  • This review alerts clinicians and clinician scientists to a common, yet often neglected, condition that occurs only upon an active change of posture and discusses its epidemiology, pathophysiology and management.[ncbi.nlm.nih.gov]
  • Several prospective epidemiological studies reported that OH is independently associated with an increased risk of developing HF.[ncbi.nlm.nih.gov]
  • Trust, London, United Kingdom; Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom. 6 Department of Cardiac, Thoracic and Vascular Sciences-Biostatistics, Epidemiology[ncbi.nlm.nih.gov]
  • This review alerts clinicians and clinician scientists to a common, yet often neglected, condition that occurs only upon an active change of posture and discusses its epidemiology, pathophysiology and management. blood pressure dizziness initial orthostatic[doi.org]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiology of IOH is thought to be a temporal mismatch between cardiac output and vascular resistance.[ncbi.nlm.nih.gov]
  • The patient's clinical features and positive tilt test only after nitroglycerine lead us to hypothesize that the arrhythmia plays a more important role in the etiology of symptoms with respect to autonomic impairment and that the pathophysiological mechanism[ncbi.nlm.nih.gov]
  • The first step is to educate the patient about the pathophysiology and course of their disorder. Nonpharmacologic therapies and maneuvers are usually effective in relieving symptoms and preventing syncope.[ncbi.nlm.nih.gov]
  • This review provides comprehensive information on OH, including pathophysiology, diagnostic workup and treatment, with a view to provide a practical guide to its management.[ncbi.nlm.nih.gov]

Prevention

  • Midodrine prevented severe falls in stroke volume, cardiac output and systolic pressure, and severe increases in heart rate without increasing vascular resistance, thus preventing orthostatic hypotension.[ncbi.nlm.nih.gov]
  • To stabilize hemodynamics and prevent presyncope symptoms in these patients, noninvasive management is preferable.[ncbi.nlm.nih.gov]
  • Interventions such as home safety assessment and preventive measures should be implemented to improve older adult's functional capacity and quality of life to prevent injury. Copyright 2017 Elsevier B.V. All rights reserved.[ncbi.nlm.nih.gov]
  • Although the AV interval did not affect the blood pressure drop in the upright position, tachypacing at 100 paces/min improved it dramatically and prevented syncope.[ncbi.nlm.nih.gov]
  • Oral midodorine and fludrocortisone therapies failed to prevent his symptoms.[ncbi.nlm.nih.gov]

References

Article

  1. Alagiakrishnan K, Patel K, Desai RV, et al. Orthostatic Hypotension and Incident Heart Failure in Community-Dwelling Older Adults. J Gerontol A Biol Sci Med Sci. 2014 Feb; 69A(2): 223–230.
  2. Robertson D, Kincaid DW, Haile V, Robertson RM. The head and neck discomfort of autonomic failure: An unrecognized aetiology of headache. Clin Auton Res. 1994 Jun;4(3):99–103. [PubMed]
  3. Kawaguchi T, Uyama O, Konishi M, Nishiyama T, Iida T. Orthostatic hypotension in elderly persons during passive standing: a comparison with young persons. J Gerontol A Biol Sci Med Sci. 2001;56:M273–M280
  4. Belmin J, Abderrhamane M, Medjahed S, et al. Variability of blood pressure response to orthostatism and reproducibility of the diagnosis of orthostatic hypotension in elderly subjects. J Gerontol A Biol Sci Med Sci. 2000;55:M667–M671.
  5. Ooi WL, Hossain M, Lipsitz LA. The association between orthostatic hypotension and recurrent falls in nursing home residents. Am J Med. 2000;108:106–111
  6. Gehrking JA, Hines SM, Benrud-Larson LM, Opher-Gehrking TL, Low PA. What is the minimum duration of head-up tilt necessary to detect orthostatic hypotension? Clin Auton Res. 2005 Apr;15(2):71–5.
  7. Goldstein DS. Dysautonomia in parkinson disease. Compr Physiol. 2014 Apr;4(2):805–26.

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Last updated: 2019-06-28 10:29