Orthostatic Hypotension
Cardiovascular
Context
Orthostatic Hypotension is the second most common etiology of syncope, occurring in approximately 15% of syncope presentations. Often unrecognized or overlooked factor associated with increased cardiovascular morbidity and all-cause mortality.
Definition
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- Orthostatic hypotension: decrease in systolic blood pressure of 20 mmHg or decrease in diastolic blood pressure of 10 mmHg within 3 minutes of standing compared with blood pressure from the sitting or supine position.
- In hypertensive subjects, a cut-off of 30 mmHg fall in sBP may be more appropriate.
- Initial orthostatic hypotension: decrease in systolic blood pressure of at least 40 mmHg or diastolic blood pressure of at least 20 mmHg within 15 seconds of standing.
- Delayed orthostatic hypotension: gradual impairment of adaptive mechanisms during orthostasis, resulting in slow decrease in sBP ≥20 mmHg or diastolic ≥10 mmHg, between 3 and 45 minutes.
- Orthostatic hypotension: decrease in systolic blood pressure of 20 mmHg or decrease in diastolic blood pressure of 10 mmHg within 3 minutes of standing compared with blood pressure from the sitting or supine position.
Underlying cause
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- Drug-induced:
- Alpha- and beta-blockers, diuretics, antiparkinsonian agents, antidepressants, anticholinergics, neuroleptics, sedatives.
- Decreased intravascular volume:
- Bleeding, dehydration, diarrhea, vomiting, heart failure.
- Neurogenic:
- lower heart rate increase when standing upright (usually <10-15 bpm) compared with nonneurogenic causes (usually >15 bpm).
- Primary: Parkinson’s disease, Dementia with Lewy bodies, Multiple system atrophy, Pure autonomic failure, Guillain-Barre syndrome.
- Secondary: DM, CKD, autoimmune diseases (Sjogren syndrome, sarcoidosis), endocrine disturbances, paraneoplastic syndromes, alcoholism, amyloidosis, infections (syphilis, HIV, Lyme), B12 deficiency.
- Drug-induced:
Diagnostic Process
Symptoms:
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- Lightheadedness.
- Dizziness.
- Presyncope, syncope.
- Head and neck pain.
- Hearing and visual disturbances.
- Weakness, leg buckling.
- Fatigue.
- Cognitive slowing.
- Orthostatic dyspnea or chest pain.
Physical exam
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- Neurological assessment looking for Parkinsonian features.
- Volume assessment: mental status, mucous membranes.
- Evaluation of suspected OH begins with consecutive BP measurements in a supine and upright positions.
- Patient should be supine for at least 5 minutes.
- After standing, measure vitals at 1 and 3 minutes to detect fall in BP and blunted (<10-15 bpm) or higher (>15 bpm) HR increase.
- In the ER, OH may be detected in most cases after 1 and 3 min of standing.
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- Identify reversible causes and underlying medical conditions:
- Look for clues on HPI:
- Vomiting, diarrhea, burns: depleted intravascular volume.
- Fever/chills: infectious.
- Pill-rolling tremor, rigidity, bradykinesia, shuffling gait: Parkinson’s.
- Progressive motor weakness: Guillain-Barre syndrome, MSA.
- Chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, extremity swelling: heart failure.
- Medical history: hypertension, diabetes, neurodegenerative disease, cardiovascular disease, renal failure, autoimmune diseases, alcohol use.
- Medication list: alpha- and beta-blockers, diuretics, tricyclic antidepressants, antiparkinsonian agents, antipsychotics.
- Look for clues on HPI:
- Identify reversible causes and underlying medical conditions:
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-
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- Once diagnosis of OH is established, basic tests should be performed:
- CBC.
- Electrolytes.
- BUN, Cr.
- Glucose.
- TSH.
- B12.
- 12-lead ECG.
- Once diagnosis of OH is established, basic tests should be performed:
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Further investigations based on history as needed
Management
The goal of treatment is to alleviate symptom burden and not to achieve target blood pressure.
Nonpharmacologic
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- Discontinue offending medications.
- If not possible, reduce dose or take at bedtime when possible.
- Antihypertensives should generally not be discontinued due to established benefits of BP lowering; uncontrolled BP can aggravate OH.
- Avoid triggers:
- Avoid large carbohydrate-rich meals to limit postprandial hypotension.
- Avoid hot environments.
- Avoid Valsalva maneuvers.
- Ensure adequate fluid and salt intake:
- Fluid intake: 2-3 L per day, rapid ingestion of water (500 mL) serves as a rescue measure.
- Salt intake: 6-10 g/day or target urinary sodium 150-200 mEq.
- Discontinue offending medications.
Lifestyle:
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- Physical maneuvers to reduce venous pooling such as rising gradually, squatting, bending over at waist.
- While actively standing, cross legs, perform thigh, abdominal, and buttock contractions.
- Exercise program focused on improving conditioning.
- Abdominal and lower extremity compression.
- In patients with supine hypertension, elevate the head of the bed to reduce nocturnal pressure natriuresis and morning volume depletion.
- Pharmacologic: should be administered in combination with lifestyle measures.
- Fludrocortisone: synthetic mineralocorticoid, considered 1st line therapy.
- Dose: start with 0.1 mg per day, titrate in increments of 0.1 mg per week, maximum 1 mg per day. Dosing should be titrated until symptoms are relieved, or until patient develops peripheral edema.
- Adverse effects: hypokalemia, headache, supine hypertension, CHF, edema.
- Patients should be advised to eat potassium-rich foods, wear compression stockings if dependent edema occurs.
- Other pharmacological therapy used: midodrine, atomoxetine, and pyridostigmine, but consider internal medicine input.
- Fludrocortisone: synthetic mineralocorticoid, considered 1st line therapy.
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Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
- Low-Moderate: consensus statements, review from AFP.
Related Information
Reference List
Non-pharmacologic management of orthostatic hypotension.
Chelimsky G, Chelimsky T. Auto Neurosci: Bas and Clin. 2020; 229.
-PubMedConsensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.
Freeman R, Wieling W, Axelrod FB, et al. Clin Auton Res. 2011; 21(2): 69-72.
-PubMedEvaluation and Management of Orthostatic Hypotension.
Lanier JB, Mote MB, Clay EC. Am Fam Physician. 2011; 84(5): 527-36.
-PubMedOrthostatic hypotension: From pathophysiology to clinical applications and therapeutic considerations.
Magkas N, Tsioufis C, Thomopoulos C, et al. J Clin Hypertens. 2019; 21: 546-554.
-PubMedMechanisms, causes, and evaluation of orthostatic hypotension.
Palma J-A, Kaufmann H, Aminoff MJ, Goddeau RP. UpToDate.
Retrieved January 10, 2022.Pharmacologic treatment of orthostatic hypotension.
Park J-W, et al. Auto Neuro: Bas and Clin. 2020; 229.
-PubMedOrthostatic Hypotension-Epidemiology, Prognosis, and Treatment.
Ricci F, Caterina RD, Fedorowski A. J Am Coll Cardio. 2015; 66(7): 848-60.
-PubMed
Related Information
OTHER RELEVANT INFORMATION
Relevant Resources
RELEVANT RESEARCH IN BC
Cardiovascular EmergenciesRESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 19, 2022
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