When to start fludrocortisone in postural hypotension
Orthostatic Hypotension (Described Concisely)
welcome our topic today is orthostatic
hypotension orthostatic hypotension also
known as postural hypotension refers to
an atypical drop in blood pressure when
a person stands up after having been
seated or lying down when standing
gravity pulls blood down away from the
brain causing arterial pressure to drop
ordinarily this drop is transient
lasting only through a few cardiac
cycles if an individual lacks the
necessary circulatory reflexes or blood
volume upon standing lesser amounts of
blood and oxygen will reach the brain
this is manifested by dizziness or
syncope and increases the patient's risk
for Falls the baroreceptor reflex
normally kicks in to compensate for
standing baroreceptors located in the
vessels of the chest and carotid sends a
decrease in blood pressure that will
lead to an increase in vasoconstriction
and an increase in heart rate to bring
blood pressure back up in the longer
term levels of epinephrine and
antidiuretic hormone increase in the
blood to also help maintain blood
pressure while standing there are
varying causes for orthostatic
hypotension hypovolemia or reduced
volume in the vascular compartment is
one of them blood pressure may be
sufficient when a person is sitting or
lying down but when they stand up they
get lightheaded some common causes for
hypovolemia may include inadequate fluid
intake excessive urination use of
diuretics excessive sweating loss of
fluids from vomiting or diarrhea and
loss of fluid that occurs from prolonged
bed rest heart conditions such as heart
attack heart failure and bradycardia
also decreased the cardiac output that
is necessary to overcome the pull of
blood away from the brain when standing
up and occur in issues like
hypothyroidism or low levels of course
such as with Addison's disease can lower
blood volume and blood pressure putting
a patient at risk for postural
hypotension
diabetes can damage neurons important in
the negative feedback loop for
increasing blood pressure when standing
many medications have the side effect of
postural hypotension and increase the
risk for patient Falls meds used for
hypertension and angina fall into this
category including alpha blockers
nitrates ACE inhibitors ARBs calcium
channel blockers and beta blockers other
drugs that may cause orthostatic
hypotension includes drugs use for
erectile dysfunction like sildenafil
sedative or anti-anxiety drugs like
benzodiazepines hypnotic drugs like
zolpidem or diphenhydramine muscle
relaxers such as cyclobenzaprine
tricyclic antidepressants or tcas
used for depression or nerve pain
dopaminergic agents used for Parkinson's
disease such as levodopa both atypical
and typical antipsychotics
anticholinergic Slyke oxybutynin opiates
like morphine and cardiac glycoside
digoxin used for heart failure or atrial
fibrillation alcohol the most commonly
used CNS depressant also increased the
risk for orthostatic hypotension since
it causes vasodilation orthostatic
hypotension becomes more of a problem
with increasing age this is due to
decreased activity of compensatory
mechanisms like the baroreceptor reflex
elderly persons also have reduced blood
volume and reduced skeletal pump
function which further complicates the
problem after age 70 patients are more
likely to experience postural
hypotension due to the aging process and
this is the most often systolic
dysfunction which causes a decrease in
blood flow to the brain
elderly patients also are more prone to
be taking antihypertensive medications
or diuretics which further compounds the
problem in addition to dizziness
patients may experience weakness and
eight Axia which may include
abnormalities in gait and speech it's
important to treat and prevent
orthostatic hypotension especially in
the elderly because fluctuations in
blood pressure to the brain increases
the risk for stroke and complications
from cardiovascular disease like angina
heart failure and arrhythmias having
healthy skeletal muscle pumps helps
blood return to the heart to increase
preload to help prevent orthostatic
hypotension being immobile and confined
to a bed brings about changes that beget
postural hypotension and mobile patients
have reduced plasma volume and decreased
muscle tone in skeletal muscle pumps all
which decrease blood returning to the
heart to decrease preload the decrease
in plasma volume is observed after only
three days of being on bed rest the
decrease in activity of skeletal muscle
pumps usually takes about two weeks of
being on bed rest
peripheral neuropathy associated with
diabetes mellitus spinal cord injury and
cerebral vascular accidents such as a
stroke can all impair autonomic nervous
system reflexes necessary to maintain
blood pressure upon standing in
neurodegenerative conditions such as
Lewy body dementia amyloidosis
Parkinson's disease and shy-drager
syndrome autonomic nervous system
neurons may fail bringing about
orthostatic hypotension to diagnose
orthostatic hypotension it is important
to obtain a thorough medical history
this includes history of syncope and
Falls medication history
and history of medical conditions blood
pressure is measured while the patient
is supine sitting and standing symptoms
while in these different positions will
be noted diagnostic criteria for
orthostatic hypotension is a decrease in
systolic pressure of at least 20
millimeters of mercury or a decrease in
diastolic pressure of at least 10
millimeters of mercury during the first
three minutes of standing a tilt table
can be used to safely move the patient
from a recumbent to standing positions
and vice versa
blood testing for hypoglycemia and
anaemia may be performed an EKG or
echocardiogram may be performed to test
for cardiac arrhythmias and for
structural changes in the heart such as
from valvular disease these tests may be
performed while walking on a treadmill
to determine heart function under stress
treatment focuses on determining the
underlying cause for example it may
involve changing medications or taking
vitamin supplements like iron or vitamin
b12 if the patient is anemic important
lifestyle modifications for patients
include standing up slowly to allow
negative feedback mechanisms to kick in
when going from a supine position to
standing it may also be helpful to sit
on the edge of the bed for a moment
before standing up and while doing so
contracting the calf muscles to increase
blood return to the heart if symptoms
come on while standing can track thigh
muscles or rise up on your toes to
contract the calf muscles if you need to
bend down to pick something up don't
bend down at the waist instead squat by
bending your knees using pillows to
elevate the head while sleeping will
decrease the chance of hypotension when
you get up it's important to avoid
things or conditions that can cause too
much vasodilation such as drinking
alcohol intense exercise in hot
environment
or saunas be aware of what may lead to
dehydration including diaphoresis lack
of fluid intake and vomiting or diarrhea
support hose or abdominal support
clothing can be used to keep blood prep
blood from pooling in the legs and
abdomen
these supporting garments should be
taken off when lying down it may be
necessary for those that have a drop in
blood pressure after meals to eat
smaller meals also measures may be taken
to increase vascular volume such as
increasing salt in the diet but should
be done in moderation and with physician
approval several medications may be used
to treat orthostatic hypotension
when lifestyle modifications are not
possible or inadequate fludrocortisone
or MIT adran are used most often
fludrocortisone is a mineral corticoid
that acts like aldosterone to help the
body retain salt in water thus
increasing blood pressure madryn is an
alpha 1 agonist that causes
vasoconstriction in arteries and veins
Troxy dopa may be used to treat
orthostatic hypotension due to certain
neurodegenerative conditions such as
Parkinson's disease Troxy dopa acts as a
prodrug
for norepinephrine and unlike
norepinephrine it can cross the
blood-brain barrier less commonly used
drugs include the following indomethacin
is intense aid that reduces vasodilation
caused by prostaglandins phenol Efrain
and clonidine are both simple mimetic
drugs phenol Efrain is an alpha 1
agonist and clonidine increases
sympathetic output to increase vascular
resistance propanolol is a non-selective
beta blocker and this action on blocking
beta 2 receptors in the vessels causes
vasoconstriction pi realistic mean is an
anti : estrus medication that increases
levels of acetylcholine in the ganglions
of the baroreceptor pathway making the
pathway more active
to resist orthostatic hypotension
without worsening supine hypertension
odd trio tied is a somatostatin analog
that causes some Veysel constriction
desmopressin nasal spray is a synthetic
form of vasopressin that increases water
retention and causes vasoconstriction to
summarize orthostatic hypotension is the
low blood pressure resulting from
inadequate blood in the brain that can
bring about syncope there are many
potential causes including conditions
that cause hypovolemia heart conditions
hypothyroidism Addison's disease and
diabetes mellitus it's also the side
effect of many medications especially
those used for hypertension and angina
advancing age and mobilization and
nervous system complications also
increase the risk treatment measures
include addressing the underlying cause
making lifestyle modifications and in
some cases using medications thanks for
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