Orthostatic Hypotension: Causes and Treatment 

Orthostatic Hypotension

Fall in the systolic blood pressure (≥20 mm Hg). Fall in diastolic blood pressure (≥10 mmhg). By changing the position from supine to standing. Lag period of three minutes (BP recorded in standing position). Mainly for the compensatory mechanisms. Autonomic tests: Tilt table test

Procedure

Patient with multiple episodes of syncope, lied in the supine

position for 20 minutes.

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Raise the head end of the bed.

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Ensure that the patient is trapped on the bed (To avoid falling)

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The head is tilted up to 70 degrees for 20- 45 minutes.

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Reproduces the symptoms of the syncope.

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Tilt back the patient to check for the Orthostatic hypotension

Postural Orthostatic Tachycardia Syndrome

Syncope is not present. BP of the patients will fall or raise or will be normal.

The levels will not fall up to the levels of Orthostatic Hypotension or syncope

Heart rate is increased by a minimum of 30 beats for minutes. Or persistently more than 120 beats per minutes

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Dysautonomia

• Wide fluctuations
• Pan body involvement
• Pupil size increases
• Functioning of the salivary glands are affected.
• Constipation or diarrhea (Damage to the sympathetic or parasympathetic system)
• Bladder issues will occur in the patients (Damage to S2, S3, or S4)
• Lower motor neuron type of the bladder that causes the overflow incontinence.
• Lesion is higher: Stroke or spinal cord damage at the cervical level or thoracic level.

Management of Orthostatic Hypotension

Abdominal binder

It presses on the mesenteric vasculature or splanchnic vessels. Improves the venous return towards the heart. Input and output of the blood is improved. Elastic compression stockings are also used. Popliteal veins and femoral veins will have lesser capacitance to hold the blood. In contrast to femoral or popliteal vessels, the splanchnic vasculature has more capacity. So abdominal binders are mostly used than the elastic compression stockings.

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Bolus water

It will increase the systolic blood pressure

Bed Up

• Standing: Orthostatic Hypertension or syncope
• Lied down.
  • Supine Hypotension
  • advised to sleep with head end of the bed slightly elevated

Countermeasures and Education

• Prevents the development of the syncope.
• Patient education will play an important role in deploying the countermeasures.
• The patient is feeling dizzy: Interlock the fingers to improve the peripheral resistance.
• Syncope with postural hypotension: Advice the patient to cross their legs.
  • Increases the venous return to the heart.
  • Delay the onset of the syncope

Drugs

Midodrine, Droxidopa

Fluids and salts

Fludrocortisone plays an important role in volume expansion

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Approach to the Patient with Orthostatic Hypotension

• Medications
  • Diuretics
  • Anti-hypertensive drugs
    • To reduce the preload (vasodilators)
    • Contribute to OH
  • Tricyclic antidepressants (overdose)
  • SSRIs (overdose)
  • Ethanol (vasodilation, flushing episodes)
  • Opioids
  • Barbiturates
• Relation to event
  • Relation to meals
  • Hot bath (increase body temperature)
  • Exercise
  • On waking up
• Heart rate variations
  • POTS: Increase in the heart rate by 30 beats per minute over or above the baseline
  • Heart rate variation with the fall of BP
  • Heart rate variation without the fall of the BP (Presentation of the POTS)
• Pupil Size
  • Horner syndrome
    • Pancoast tumor
    • Sympathomimetic drive is affected.
  • Holmes Adie pupil
    • Damage to the ciliary ganglion
    • Post ganglionic damage with respect to the parasympathetic nervous system affected.
    • Denervation hypersensitivity is seen (Pupil will become sensitive to the drug at very dilute solutions)
  • Characteristics
    • Unilateral or bilateral tonically dilated pupils
    • Due to the sympathomimetic drive, postganglionic fibers are affected.
    • Abnormal reactions to light.
    • Near light dissociation
    • Development of tendon areflexia

Orthostatic Hypotension: Causes

Neurogenic

Mortality rates are 3-7 times higher

Non-neurogenic

• Over treatment with anti-hypertensive medicines and with :-
  • TCA
  • SSRIs
  • Ethanol
  • Barbiturates
  • Opioids
• Anemia
  • May contribute to tachycardia, palpitations, and orthostatic hypotension.
• Volume depletion or dehydration.

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Overall Manifestations

• OH, is the most common & most disabling feature of autonomic dysfunction.
• Neurogenic OH - Mortality Rate is 3-7x higher.
• Lightheadedness / Dizziness is the most common symptom in OH.

Clinical Features

• Counter maneuvers should be deployed in lightheadedness, dizziness, and blurred vision; thus, minimize the chances of OH can be minimized.
• Orthostatic Intolerance—dizziness, blurred vision,
• Syncope.
• Sleep disturbances.
• Altered sweating.
  • Hyperhidrosis → ↓ Body Temperature.
  • Anhidrosis → ↑ Body Temperature - Pseudomotor failure.
• Impotence and erectile dysfunction can be seen in males.
  • Primary manifestation: Early morning erections with relatively less frequency.
• Bladder dysfunction.
  • Damage at the level of S2, S3, S4 - Flaccid bladder, post void residual urine, overflow incontinence (No response to the traditional stimulus - Denervation), urge incontinence (Damage in brain or in spinal cord).
• Diarrhea or constipation.

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