Orthostatic hypotension
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sogand Goudarzi, MD [2]
Synonyms and keywords: Postural hypotension; orthostatic intolerance; head rush; dizzy spell
Overview
Orthostatic hypotension is a sudden fall in blood pressure, typically greater than 20/10 mm Hg, that occurs when a person assumes a more vertical postion such as from sitting to standing or from lying down to sitting or standing , usually after a prolonged period of rest.
Causes
Common Causes
Common causes of orthostatic hypotension may include:[1]
- Medical conditions:hjgdsgdkjshf
- Pregnancy
- Heart problems: Bradycardia, heart valve problems, heart attack and heart failure.
- Dehydration: Fever, vomiting, severe diarrhea, overuse of diuretics and strenuous exercise can lead to dehydration.
- Endocrine problems
- Blood loss
- Septicemia
- Aanaphylaxis: reaction include foods, certain medications, insect venoms and latex.
- Anemia: Lack of nutrients (vitamins B-12, folate)
- Medication:
- Apomorphine hydrochloride
- Bromocriptine
- Cidofovir
- Entacapone
- Ethacrynic Acid
- Fluphenazine
- Hydrochlorothiazide
- Iloperidone
- Loxapine
- Niacin
- Pergolide
- Perphenazine
- Rasagiline
- Risperidone
- Ritonavir
- Rotigotine
- Thioridazine hydrochloride
- Thiothixene,
- Tiagabine
- Vincristine sulfate liposome
- Orthostatic hypotension is primarily caused by gravity-induced blood pooling in the lower extremities, which in turn compromises venous return, resulting in decreased cardiac output and subsequently lowering of arterial pressure. For example, if a person changes from a lying position to standing, he or she will lose about 700 ml of blood from the thorax. It can also be noted that although there is a decreased systolic (contracting) blood pressure, there is actually an increased diastolic (resting) blood pressure. However, the overall effect is an insufficient blood perfusion in the upper part of the body.
- Still, the blood pressure does not normally fall very much, because it immediately triggers a vasoconstriction, pressing the blood up into the body again. Therefore, a secondary factor is required that, in turn, cause a fall in blood pressure greater than normal. Such factors include hypovolemia, associated disease states, pharmacotherapy, or, very rarely, safety harnesses[2].
- Drug side effects
Hypovolemia
Orthostatic hypotension may be caused by hypovolemia (a decreased amount of blood in the body), resulting from bleeding, the excessive use of diuretics, vasodilators, or other types of drugs, dehydration, or prolonged bed rest. It also occurs in people with anemia ,pregnancy in females and venous varicosities .Certain circulating endogenous vasodilators which causes hyperbardykinism and mastocytosis may also cause postural hypotension.
Diseases
The disorder may be associated with Addison's disease, atherosclerosis (build-up of fatty deposits in the arteries), amyloidosis, alcohol neuropathy, spinal cord disease, multiple sclerosis, multiple cerebral infarcts, Tabes Dorsalis, Syringomyelia, idiopathic orthostatic hypotension, diabetes, carcinoid syndrome, pheochromocytoma, and certain neurological disorders including Shy-Drager syndrome and other forms of dysautonomia. It is also associated with Ehlers-Danlos Syndrome
It is also present in many patients with Parkinson's Disease resulting from sympathetic denervation of the heart or as a side effect of dopaminomimetic therapy. This rarely leads to syncope unless the patient has developed true autonomic failure or has an unrelated cardiac problem.
Medication
Orthostatic hypotension can result from antihypertensive medicines such as diuretics especially furosemide, Lisinopril and Hydrochlorothiazide, Beta Blockers, Calcium channel blockers and ACE Inhibitors,Prazosin and Tamsulosin which is a drug for treatment of Benign prostatic hyperplasia. Nitrates have shown to cause side effects of postural hypotension. It can also be the side effect of certain anti-psychotics such as Clozapine, zotepine, Olanzapine, neuroleptics ,sedative hypnotics and anti-depressants, such as duloxetine, tricyclics[3] or MAOIs.[4] It is also a side effect of the short-term use of marijuana. like Nabilone.[5] Dopamine agonists such as Pramipexole, and ropinirole can cause orthostatic hypotension.
Harnesses
The use of a safety harness can also contribute to orthostatic hypotension in the event of a fall. While a harness may safely rescue its user from a fall, the leg loops of a standard safety or climbing harness further restrict return blood flow from the legs to the heart, contributing to the decrease in blood pressure.
Risk Factors
Common risk factors in the development of orthostatic hypotension include:[6][7]
- Age (y>65)
- Medications (alpha blockers)
- Disease: Parkinson's disease, diabetes
- Postpartum mothers
- Patients who have been on bedrest.
Natural History
- The symptoms of orthostatic hypotension usually develop in the first/ second/ third decade of life, and start with symptoms such as ___.
- The symptoms of (disease name) typically develop ___ years after exposure to ___.
- If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
Complications
Common complications of orthostatic hypotension include:[8][9]
- Moderate low blood pressure:
- Severely low blood pressure:
- Heart damage (Heart failur)
- Brian damage (Stroke)
Prognosis
- Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [--]%.
- Depending on the extent of the [tumor/disease progression] at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as poor/good/excellent.
- The presence of [characteristic of disease] is associated with a particularly [good/poor] prognosis among patients with [disease/malignancy].
- [Subtype of disease/malignancy] is associated with the most favorable prognosis.
- The prognosis varies with the [characteristic] of tumor; [subtype of disease/malignancy] have the most favorable prognosis.
Diagnosis
History and Symptoms
Symptoms, which generally occur after sudden standing, include dizziness, lightheadedness, headache, blurred or dimmed vision (possibly to the point of momentary blindness), and fainting. They are consequences of insufficient blood pressure and cerebral perfusion(blood supply).
Symptoms
Physical Examination
- Patients with orthostatic hypotension usually appear well, pallor and tiredness. [13]
- Physical examination may be remarkable for:
- Fall in blood pressure, typically greater than 20/10 mm
Treatment
Medical Therapy
There are medications to treat hypotension. In addition, there are many lifestyle advices. Many of them, however, are specific for a certain cause of orthostatic hypotension.
Some drugs that are used in the treatment of orthostatic hypotension include fludrocortisone (Florinef), erythropoietin and midodrine. Pyridostigmine bromide (Mestinon) is now also used to treat orthostatic hypotension.[14][15][16]
- Treatment of neurogenic orthostatic hypotension:[17]
- Avoid triggers: large meals, hot bath, prolong standig
Lifestyle Advice
Some suggestions for minimizing the effects include:
- Checking blood pressure regularly with a home monitoring kit. Check when lying flat and when standing as well as when symptoms occur.
- Standing slowly rather than quickly, as the delay can give the blood vessels more time to constrict properly. This can help avoid incidents of syncope (fainting).
- Take a deep breath and flex your abdominal muscles while rising to maintain blood and oxygen in the brain. This, however, may be contraindicated in individuals with Stage 3 hypertension. Usually medical personnel have their patients "dangle" before rising from bed to decrease the likelihood of dizziness / falling due to orthostatic hypotension. The dangling is done by having the patient sit on the side of their bed for about a minute so they do not have the sudden dizziness.
- Maintaining an elevated salt intake, through sodium supplements or electrolyte-enriched drinks. A suggested value is 10 g per day; overuse can lead to hypertension and should be avoided.
- Maintaining a proper fluid intake to prevent the effects of dehydration.
- As eating lowers blood pressure, eat multiple smaller meals rather than fewer larger meals. Take extra care when standing after eating.
- When orthostatic hypotension is caused by hypovolemia due to medications, the disorder may be reversed by adjusting the dosage or by discontinuing the medication.
- When the condition is caused by prolonged bed rest, improvement may occur by sitting up with increasing frequency each day. In some cases, physical counterpressure such as elastic hose or whole-body inflatable suits may be required.
References
- ↑ Hohmann M, Künzel W (1991). "Orthostatic hypotension and birthweight". Arch. Gynecol. Obstet. 248 (4): 181–9. doi:10.1007/bf02390357. PMID 1898124.
- ↑ Suspension trauma. Lee C, Porter KM.
- ↑ Jiang W, Davidson JR. (2005). "Antidepressant therapy in patients with ischemic heart disease". Am Heart J. 150 (5): 871–81. PMID 16290952.
- ↑ Delini-Stula A, Baier D, Kohnen R, Laux G, Philipp M, Scholz HJ. (1999). "Undesirable blood pressure changes under naturalistic treatment with moclobemide, a reversible MAO-A inhibitor--results of the drug utilization observation studies". Pharmacopsychiatry. 32 (2): 61–7. PMID 10333164.
- ↑ Jones RT. (2002). "Cardiovascular system effects of marijuana". J Clin Pharmacol. 42 (11 Suppl): 58S–63S. PMID 12412837.
- ↑ Arnold, Amy C.; Shibao, Cyndya (2013). "Current Concepts in Orthostatic Hypotension Management". Current Hypertension Reports. 15 (4): 304–312. doi:10.1007/s11906-013-0362-3. ISSN 1522-6417.
- ↑ Canobbio, Mary M.; Warnes, Carole A.; Aboulhosn, Jamil; Connolly, Heidi M.; Khanna, Amber; Koos, Brian J.; Mital, Seema; Rose, Carl; Silversides, Candice; Stout, Karen (2017). "Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association". Circulation. 135 (8). doi:10.1161/CIR.0000000000000458. ISSN 0009-7322.
- ↑ Romero-Ortuno R, Cogan L, Foran T, Kenny RA, Fan CW (April 2011). "Continuous noninvasive orthostatic blood pressure measurements and their relationship with orthostatic intolerance, falls, and frailty in older people". J Am Geriatr Soc. 59 (4): 655–65. doi:10.1111/j.1532-5415.2011.03352.x. PMID 21438868.
- ↑ Ricci, Fabrizio; Fedorowski, Artur; Radico, Francesco; Romanello, Mattia; Tatasciore, Alfonso; Di Nicola, Marta; Zimarino, Marco; De Caterina, Raffaele (2015). "Cardiovascular morbidity and mortality related to orthostatic hypotension: a meta-analysis of prospective observational studies". European Heart Journal. 36 (25): 1609–1617. doi:10.1093/eurheartj/ehv093. ISSN 0195-668X.
- ↑ Bleasdale-Barr KM, Mathias CJ (July 1998). "Neck and other muscle pains in autonomic failure: their association with orthostatic hypotension". J R Soc Med. 91 (7): 355–9. doi:10.1177/014107689809100704. PMC 1296807. PMID 9771493.
- ↑ Khurana RK (July 2012). "Coat-hanger ache in orthostatic hypotension". Cephalalgia. 32 (10): 731–7. doi:10.1177/0333102412449932. PMID 22711896.
- ↑ Robertson D, Kincaid DW, Haile V, Robertson RM (June 1994). "The head and neck discomfort of autonomic failure: an unrecognized aetiology of headache". Clin. Auton. Res. 4 (3): 99–103. doi:10.1007/bf01845772. PMID 7994169.
- ↑ Stewart JM (May 2013). "Common syndromes of orthostatic intolerance". Pediatrics. 131 (5): 968–80. doi:10.1542/peds.2012-2610. PMC 3639459. PMID 23569093.
- ↑ Singer W, Opfer-Gehrking TL, McPhee BR, Hilz MJ, Bharucha AE, Low PA. (2003). "Acetylcholinesterase inhibition: a novel approach in the treatment of neurogenic orthostatic hypotension". J Neurol Neurosurg Psychiatry. 74 (9): 1294–8. PMID 12933939.
- ↑ Figueroa, J. J.; Basford, J. R.; Low, P. A. (2010). "Preventing and treating orthostatic hypotension: As easy as A, B, C". Cleveland Clinic Journal of Medicine. 77 (5): 298–306. doi:10.3949/ccjm.77a.09118. ISSN 0891-1150.
- ↑ Freeman, Roy; Abuzinadah, Ahmad R.; Gibbons, Christopher; Jones, Pearl; Miglis, Mitchell G.; Sinn, Dong In (2018). "Orthostatic Hypotension". Journal of the American College of Cardiology. 72 (11): 1294–1309. doi:10.1016/j.jacc.2018.05.079. ISSN 0735-1097.
- ↑ Freeman, Roy; Abuzinadah, Ahmad R.; Gibbons, Christopher; Jones, Pearl; Miglis, Mitchell G.; Sinn, Dong In (2018). "Orthostatic Hypotension". Journal of the American College of Cardiology. 72 (11): 1294–1309. doi:10.1016/j.jacc.2018.05.079. ISSN 0735-1097.
External Links
- John G. Bradley, M.D., and Kathy A. Davis, R.N. Orthostatic Hypotension American Family Physician
- DYNA Dysautonomia Youth Network of America, Inc.