Updated: 10/11/2018

Orthostatic Hypotension

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Snapshot
  • A 66-year-old man presents to his primary care physician for generalized weakness and episodes of lightheadedness. He says that his symptoms began approximately a few weeks ago after there was a change in his blood pressure medications. Medical history is significant for hypertension and newly diagnosed benign prostatic hyperplasia. After being in the supine position for 5 minutes, he was asked to stand, and a blood pressure was obtained 3 minutes after standing. There was a 23 mmHg decrease in systolic blood pressure. 
Introduction
  • Clinical definition
    • a decrease in blood pressure while the patient is standing compared to when they are sitting or in a supine position
      • ≥ 20 mmHg decrease in systolic blood pressure OR
      • ≥ 10 mmHg decrease in diastolic blood pressure
  • Epidemiology
    • incidence
      • commonly seen in the elderly
        • likely secondary to impaired baroreceptor sensitivity
    • risk factors
      • antihypertensive medications
      • diuretics
      • volume depletion (e.g., vomiting and hemorrhage)
  • Etiology
    • autonomic failure
    • volume depletion/dehydration
      • most common cause in the elderly 
        • while not necessary for diagnosis, may show decreased FENa (<1%)
    • medications (e.g., terazosin)
  • Pathophysiology
    • physiology
      • gravitational pooling of blood decreases venous return, cardiac output, and blood pressure
      • compensatory mechanisms regulate blood pressure by controlling
        • vasoconstriction
        • heart rate
        • cardiac contractility
    • pathogenesis
      • failure of compensatory mechanisms to regulate blood pressure when the patient is in the upright position
        • e.g., autonomic failure
Presentation
  • Symptoms
    • dizziness
    • lightheadedness
    • vision changes (e.g., vision blurring or darkening)
    • generalized weakness
Studies
  • Blood pressure measurements
    • obtain blood pressure measurements 2-5 minutes after the patient is standing from a supine position
      • it is diagnosed if there is 
        • ≥ 20 mmHg decrease in systolic blood pressure OR
        • ≥ 10 mmHg decrease in diastolic blood pressure
  • Electrocardiogram
    • performed to rule-out cardiac arrhythmia
Treatment
  • Conservative
    • treat the underlying cause
      • e.g., medication alterations
    • dietary modification
      • in the absence of hypertension, the patient should increase fluid and salt intake
  • Medical
    • midodrine or fludrocortisone
      • indication
        • indicated in patients who do not respond to conservative treatment
Complications
  • There is an increased cardiovascular and all-cause mortality

References

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