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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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