Evaluation and Management of Orthostatic Hypotension

1 Evaluation and Management of Orthostatic Hypotension JEFFREY B. LANIER, MD; MATTHEW B. MOTE, DO; and EMILY C. CLAY, MD. Martin Army Community Hospital Family Medicine Residency, Fort Benning, Georgia Orthostatic Hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural changes in blood pressure. Orthostatic Hypotension may be acute or chronic, as well as symptomatic or asymptomatic. Common symptoms include dizzi- ness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache.

2 Less common symp- toms include syncope, dyspnea, chest pain, and neck and shoulder pain. Causes include dehydration or blood loss;. disorders of the neurologic, cardiovascular, or endocrine systems; and several classes of medications. Evaluation of suspected Orthostatic Hypotension begins by identifying reversible causes and underlying associated medical condi- tions. Head-up tilt-table testing can aid in confirming a diagnosis of suspected Orthostatic Hypotension when standard Orthostatic vital signs are nondiagnostic; it also can aid in assessing treatment response in patients with an autonomic disorder. Goals of treatment involve improving Hypotension without excessive supine hypertension, relieving ortho- static symptoms, and improving standing time.

3 Treatment includes correcting reversible causes and discontinuing responsible medications, when possible. Nonpharmacologic treatment should be offered to all patients. For patients who do not respond adequately to nonpharmacologic treatment, fludrocortisone, midodrine, and pyridostigmine are pharmacologic therapies proven to be beneficial. (Am Fam Physician. 2011;84(5):527-536. Copyright 2011 Ameri- can Academy of Family Physicians.). O. Pathophysiology . Patient information: rthostatic Hypotension is defined A handout on Orthostatic Hypotension , written by as a decrease in systolic blood A normal hemodynamic response to the authors of this article, pressure of 20 mm Hg or a changes in posture requires normal func- is provided on page 537.

4 Decrease in diastolic blood pres- tion of the cardiovascular and autonomic sure of 10 mm Hg within three minutes of nervous systems. Standing results in blood standing compared with blood pressure from pooling of approximately 500 to 1,000 mL. the sitting or supine position. Alternatively, in the lower extremities and splanchnic cir- the diagnosis can be made by head-up tilt- culation. This initiates an increase in sym- table testing at an angle of at least 60 pathetic outflow, which increases peripheral Orthostatic Hypotension is often found in vascular resistance, venous return, and car- older patients and in those who are It diac output, thereby limiting the decrease is present in up to 20 percent of patients older in blood pressure.

5 Than 65 In one study, the prevalence These compensatory mechanisms result of Orthostatic Hypotension was 18 percent in in a decrease in systolic blood pressure (5 to patients older than 65 years, but only 2 per- 10 mm Hg), an increase in diastolic blood cent of these patients were pressure (5 to 10 mm Hg), and an increase in In the absence of volume depletion, pulse rate (10 to 25 beats per minute). How- younger patients with Orthostatic hypoten- ever, Orthostatic Hypotension may result if sion usually have chronic autonomic failure. there is inadequate intravascular volume, A related problem, postprandial hypoten- autonomic nervous system dysfunction, sion, is common in older patients and those decreased venous return, or inability to with autonomic dysfunction.

6 In postpran- increase cardiac output in response to pos- dial Hypotension , there is a decrease in sys- tural Decreased cerebral perfu- tolic blood pressure of at least 20 mm Hg sion produces the neurologic symptoms of within 75 minutes of a Orthostatic Downloaded from the American Family Physician Web site at Copyright 2011 American Academy of Family Physicians. For the private, noncommercial September use 1, 2011 American requests. 527. Family Physician Volume 84, Number 5. of one individual user of the Web site. All other rights reserved. Contact for copyright questions and/or permission Orthostatic Hypotension SORT: KEY RECOMMENDATIONS FOR PRACTICE. Evidence Clinical recommendation rating References Consider head-up tilt-table testing in patients with symptoms of C 6, 14.

7 Orthostatic Hypotension despite normal vital signs, or in patients who are unable to stand for Orthostatic vital sign measurements. Patients with chronic Orthostatic Hypotension should be counseled C 6, 22. to avoid large carbohydrate-rich meals, limit alcohol intake, and ensure adequate hydration. Fludrocortisone, midodrine, and pyridostigmine (Mestinon) are B 26, 28, 29. effective therapies for chronic Orthostatic Hypotension . A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to Clinical Presentation and Evaluation may present with neck and shoulder pain, Orthostatic Hypotension may be acute or Orthostatic dyspnea, and chest Table 1.

8 Chronic. Patients may present with light- outlines the differential diagnosis of ortho- headedness, blurred vision, dizziness, weak- static Hypotension , which may be caused by ness, and fatigue, or with syncope (in the a number of things, including dehydration, acute care setting).6 Less commonly, they blood loss, medication, or a disorder of the neurologic, cardiovascular, or endocrine sys- Evaluation of suspected Orthostatic Table 1. Differential Diagnosis of Orthostatic Hypotension Hypotension begins by identifying reversible causes and underlying associated medical Cardiovascular 8-10 Endocrine10 conditions. Table 2 lists historical features Anemia Adrenal insufficiency that suggest a specific diagnosis in the Cardiac arrhythmia Diabetes insipidus patient with Orthostatic ,8 In Congestive heart failure Hyperglycemia, acute addition to assessing for symptoms of ortho- Myocardial infarction Hypoaldosteronism stasis.

9 The physician should elicit symptoms Myocarditis Hypokalemia of autonomic dysfunction involving the gas- Pericarditis Hypothyroidism trointestinal and genitourinary Valvular heart disease Pheochromocytoma Key physical examination findings in the Venous insufficiency Intravascular volume depletion 8-10 Evaluation of suspected Orthostatic hypoten- Drugs10 Blood loss sion are listed in Table ,12 A detailed assess- Alcohol Dehydration ment of the motor nervous system should be Antiadrenergics Pregnancy/postpartum performed to evaluate for signs of Parkinson Antianginals Shock disease, as well as cerebellar Blood Antiarrhythmics Miscellaneous 8-10 pressure and pulse rate should be measured Anticholinergics AIDS in the supine position and repeated after the Antidepressants Anxiety or panic disorder patient has been standing for three min- Antihypertensives Eating disorders Antiparkinsonian agents utes.

10 As many as two-thirds of patients with Prolonged bed rest Diuretics Orthostatic Hypotension may go undetected Narcotics if blood pressure is not measured while Neuroleptics However, a retrospective review Sedatives of 730 patients found that Orthostatic vital signs had poor test characteristics (positive Information from references 8 through 10. predictive value = percent; negative pre- dictive value = percent) when compared 528 American Family Physician Volume 84, Number 5 September 1, 2011. Orthostatic Hypotension Table 2. Historical Clues to Diagnosis of Orthostatic Hypotension Historical features Possible etiology Abnormal uterine bleeding, fatigue, rectal bleeding Anemia Amaurosis fugax, aphasia, dysarthria, unilateral Stroke sensory and motor symptoms Bradykinesia, pill-rolling tremor, shuffling gait Parkinson disease Burns Intravascular volume depletion Chest pain, palpitations, shortness of breath Congestive heart failure, myocardial infarction, myocarditis, pericarditis Chills, fever, lethargy, nausea, vomiting Gastroenteritis, sepsis Extremity swelling Congestive heart failure, venous insufficiency High-risk sexual behavior AIDS.