Orthostatic hypotension facts
What is orthostatic hypotension?
When a person stands up from sitting or lying down, the body must work to adjust to that change in position. It is especially important for the body to push blood upward and supply the brain with oxygen. If the body fails to do this adequately, blood pressure falls, and a person may feel lightheaded or even pass out. Orthostatic hypotension is the term used to describe the fall in blood pressure when a person stands (orthostatic= upright posture of the body; hypo= less + tension=pressure).
Adequate blood supply to the body's organs depends upon three factors:
When the body changes position, a variety of actions occur involving all parts of the cardiovascular system as well as the autonomic nervous system that helps regulate their function.
The autonomic nervous system can be considered to "run in the background" of the body, regulating body processes that we take for granted. There is a balance between the sympathetic system (adrenergic nerves), that speed things up, and the parasympathetic system (cholinergic nerves) that slow things down. These names are based on the type of chemical that is used to transmit signals at the nerve endings.
These two systems are in balance, and yet need to respond to routine changes in the body that happens throughout the day.
Orthostatic hypotension is not a disease or a complaint from an individual; it is an abnormal change in blood pressure and heart rate associated with an illness.
What causes orthostatic hypotension?
Orthostatic hypotension has many potential causes, some affecting only one part of the system that supplies blood to the brain, and others affecting two or three.
Loss of fluid within the blood vessels is the most common reason to develop the symptoms of orthostatic hypotension. The fluid may be water or blood depending upon the cause.
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A vasovagal episode is a condition that may occur when a stimulus causes excess activation of the parasympathetic system, slowing the heart rate and dilating blood vessels. Symptoms of lightheadedness or fainting then occur due to the lowering of blood pressure and decrease in blood flow to the brain. The stimulus may be pain from an injury such as a broken bone, or there may be a psychologic trigger, such as a medical student watching a first operation. The vagus nerve that causes this response may also in some cases be triggered by urinating (micturition syncope) or by pushing hard to have a bowel movement.
Patients with diabetes may develop peripheral neuropathy that can affect nerves of the autonomic nervous system, and as a result, may develop orthostatic hypotension. As well, patients with poorly-controlled diabetes have the potential of becoming dehydrated.
Some patients may develop post-prandial lightheadedness, meaning that symptoms occur after a heavy meal. In this case, the body dilates blood vessels to the stomach and intestine to help with digestion, leaving less blood available to flow to the brain.
Addison's Disease, or adrenal insufficiency, may also be associated with the inability of the body to compensate for position change.
There are a variety of reasons that heart disease may cause orthostatic hypotension. Abnormalities of the electrical conduction system including heart rates that are too slow or too fast may cause changes in blood pressure. Patients with heart valve disorders, heart failure, and heart attack may all experience orthostatic hypotension.
Disorders of the nervous system may also cause orthostatic hypotension. Examples include Parkinsonism, amyloidosis, and Shy-Drager Syndrome (or multiple system atrophy).
Postural orthostatic tachycardia syndrome describes the feeling of lightheadedness, nausea, fatigue, and weakness associated with an elevated heart rate (greater than 120 beats per minute) that begins within 10 minutes of a heads-up tilt table test. It is often seen in younger females between the ages of 12 and 50, and there may be a relationship with chronic fatigue syndrome.
What are the risk factors for orthostatic hypotension?
Orthostatic hypotension most often occurs in the elderly. "Hardening of the arteries" or atherosclerosis that develops as we age makes it more difficult for blood vessels to adapt quickly when necessary. As well, many of the diseases that are associated with orthostatic hypotension are progressive, with symptoms worsening with age.
Pregnancy is associated with orthostatic hypotension. As the pregnancy progresses, the volume of the circulatory system expands and blood pressure tends to fall. This may lead to lightheadedness when standing quickly. Blood pressure levels return to normal after delivery.
Excessive sweating due to physical exertion and exposure to heat are risk factors and potential causes of dehydration and symptoms of orthostatic hypotension. Patients who have other risk factors to develop orthostatic hypotension have an increased risk if they become even mildly dehydrated.
Chronic alcohol use and drug abuse are also risk factors for developing symptoms of orthostatic hypotension.
What are the symptoms of orthostatic hypotension?
When the brain does not get enough blood supply, it begins to shut down.
Symptoms include:
There may also be weakness, blurred vision, and shaking or tremulousness.
These symptoms may resolve quickly as the body slowly adjusts to the standing position, but in some cases the patient has to sit or lie down quickly to prevent passing out or falling.
When should I call the doctor for orthostatic hypotension?
Feeling faint or lightheaded is not normal. While a rare episode that can be explained by circumstances, such as working or exercising in the heat, may be ignored, more frequent occurrences should be investigated.
If a person passes out and is unconscious, even for a short period of time, is never normal and medical care should be accessed.
How is orthostatic hypotension diagnosed?
The key to the diagnosis is a good history and physical examination. The health care practitioner will want to know the circumstances that are associated with the symptoms of lightheadedness or passing out, since the patient is unlikely to have taken their blood pressure and checked their pulse rate in the midst of the episode.
The symptoms tend to be transient and resolve quickly. Should there be concern that the vital signs will change with position, the health care practitioner will take the blood pressure in both lying and standing positions and look for changes.
According to the American Academy of Neurology, the formal diagnosis of orthostatic hypotension requires a 20mm drop in systolic blood pressure or a 10mm drop in diastolic blood pressure within three minutes of standing. Often there is an associated increase in the heart rate, especially if dehydration or bleeding is the cause (if the patient is taking a beta blocker, the heart rate may not be able to respond with an increase).
Blood tests may be ordered to look for the underlying cause. These may include a red blood cell count (CBC) to access for anemia or bleeding. Electrolytes may be checked, especially if there has been a history of fluid loss through vomiting or diarrhea, since sodium and potassium abnormalities may be an issue. Kidney function may be assessed.
If the physical examination reveals concern about the heart, an electrocardiogram (EKG) may be done to evaluate electrical conduction and heart rhythm. An echocardiogram or ultrasound of the heart may be ordered to evaluate the heart valves and assess the function of the heart muscle. A stress test may be considered if there is concern about coronary artery disease.
A heads-up tilt table test may be ordered if the symptoms of orthostatic hypotension continue to recur but it has been difficult to document abnormalities in blood pressure readings. During the test, the patient is strapped flat on a table, and as the table gradually is tilted to a 70 or 80 degree angle, continuous blood pressure and heart rate readings are taken. The patient may be left on the table for more than 10 minutes to look for the delayed changes seen in postural orthostatic tachycardia syndrome.
For many patients, the diagnosis may be made based upon the history and physical examination, and no further testing may be needed.
What is the treatment for orthostatic hypotension?
The treatment for orthostatic hypotension depends upon the underlying diagnosis. If the cause is dehydration, then fluid replacement will resolve the symptoms. If it is due to medication, then an adjustment of the dose or change in the type of medicine taken may be required.
Compression stockings may be considered to help prevent fluid from pooling in the legs when a person is sitting or lying down. This allows for more blood flow to be available to the brain when changes in position occur.
Medications may be of use, again depending upon the underlying cause of the orthostatic hypotension. For those who are otherwise healthy and have no specific illness that must be treated, increased salt and fluid intake may be recommended. Caffeine and nonsteroidal antiinflammatory medications for example, ibuprofen may also be suggested.
Some patients may be a candidate for fludrocortisone (Florinef) to increase the volume of fluid in the blood vessels. Fludrocortisone is an adrenergic (adrenaline-mimicking) drug, which stimulates the sympathetic nervous system. This medication does have significant side effects, including lowering magnesium and potassium levels in the blood, headache, swelling, and weight gain.
Learn more about: Florinef
What are the complications of orthostatic hypotension?
Falling is the most important complication of orthostatic hypotension. Most often, the symptoms are transient and self- limiting, giving the patient a chance to sit down, but when the drop in blood pressure causes syncope (fainting) or near syncope, it is the trauma that is sustained in the fall that causes the most damage.
What is orthostatic hypotension?
When a person stands up from sitting or lying down, the body must work to adjust to that change in position. It is especially important for the body to push blood upward and supply the brain with oxygen. If the body fails to do this adequately, blood pressure falls, and a person may feel lightheaded or even pass out. Orthostatic hypotension is the term used to describe the fall in blood pressure when a person stands (orthostatic= upright posture of the body; hypo= less + tension=pressure).
Adequate blood supply to the body's organs depends upon three factors:
When the body changes position, a variety of actions occur involving all parts of the cardiovascular system as well as the autonomic nervous system that helps regulate their function.
The autonomic nervous system can be considered to "run in the background" of the body, regulating body processes that we take for granted. There is a balance between the sympathetic system (adrenergic nerves), that speed things up, and the parasympathetic system (cholinergic nerves) that slow things down. These names are based on the type of chemical that is used to transmit signals at the nerve endings.
These two systems are in balance, and yet need to respond to routine changes in the body that happens throughout the day.
Orthostatic hypotension is not a disease or a complaint from an individual; it is an abnormal change in blood pressure and heart rate associated with an illness.
What causes orthostatic hypotension?
Orthostatic hypotension has many potential causes, some affecting only one part of the system that supplies blood to the brain, and others affecting two or three.
Loss of fluid within the blood vessels is the most common reason to develop the symptoms of orthostatic hypotension. The fluid may be water or blood depending upon the cause.
Learn more about: Inderal | Viagra | Levitra | Cialis | Nitrostat | Nitro-Dur | Ismo | Elavil | Pamelor | Thorazine | Mellaril | Compazine | Nardil | Parnate
A vasovagal episode is a condition that may occur when a stimulus causes excess activation of the parasympathetic system, slowing the heart rate and dilating blood vessels. Symptoms of lightheadedness or fainting then occur due to the lowering of blood pressure and decrease in blood flow to the brain. The stimulus may be pain from an injury such as a broken bone, or there may be a psychologic trigger, such as a medical student watching a first operation. The vagus nerve that causes this response may also in some cases be triggered by urinating (micturition syncope) or by pushing hard to have a bowel movement.
Patients with diabetes may develop peripheral neuropathy that can affect nerves of the autonomic nervous system, and as a result, may develop orthostatic hypotension. As well, patients with poorly-controlled diabetes have the potential of becoming dehydrated.
Some patients may develop post-prandial lightheadedness, meaning that symptoms occur after a heavy meal. In this case, the body dilates blood vessels to the stomach and intestine to help with digestion, leaving less blood available to flow to the brain.
Addison's Disease, or adrenal insufficiency, may also be associated with the inability of the body to compensate for position change.
There are a variety of reasons that heart disease may cause orthostatic hypotension. Abnormalities of the electrical conduction system including heart rates that are too slow or too fast may cause changes in blood pressure. Patients with heart valve disorders, heart failure, and heart attack may all experience orthostatic hypotension.
Disorders of the nervous system may also cause orthostatic hypotension. Examples include Parkinsonism, amyloidosis, and Shy-Drager Syndrome (or multiple system atrophy).
Postural orthostatic tachycardia syndrome describes the feeling of lightheadedness, nausea, fatigue, and weakness associated with an elevated heart rate (greater than 120 beats per minute) that begins within 10 minutes of a heads-up tilt table test. It is often seen in younger females between the ages of 12 and 50, and there may be a relationship with chronic fatigue syndrome.
What are the risk factors for orthostatic hypotension?
Orthostatic hypotension most often occurs in the elderly. "Hardening of the arteries" or atherosclerosis that develops as we age makes it more difficult for blood vessels to adapt quickly when necessary. As well, many of the diseases that are associated with orthostatic hypotension are progressive, with symptoms worsening with age.
Pregnancy is associated with orthostatic hypotension. As the pregnancy progresses, the volume of the circulatory system expands and blood pressure tends to fall. This may lead to lightheadedness when standing quickly. Blood pressure levels return to normal after delivery.
Excessive sweating due to physical exertion and exposure to heat are risk factors and potential causes of dehydration and symptoms of orthostatic hypotension. Patients who have other risk factors to develop orthostatic hypotension have an increased risk if they become even mildly dehydrated.
Chronic alcohol use and drug abuse are also risk factors for developing symptoms of orthostatic hypotension.
What are the symptoms of orthostatic hypotension?
When the brain does not get enough blood supply, it begins to shut down.
Symptoms include:
There may also be weakness, blurred vision, and shaking or tremulousness.
These symptoms may resolve quickly as the body slowly adjusts to the standing position, but in some cases the patient has to sit or lie down quickly to prevent passing out or falling.
When should I call the doctor for orthostatic hypotension?
Feeling faint or lightheaded is not normal. While a rare episode that can be explained by circumstances, such as working or exercising in the heat, may be ignored, more frequent occurrences should be investigated.
If a person passes out and is unconscious, even for a short period of time, is never normal and medical care should be accessed.
How is orthostatic hypotension diagnosed?
The key to the diagnosis is a good history and physical examination. The health care practitioner will want to know the circumstances that are associated with the symptoms of lightheadedness or passing out, since the patient is unlikely to have taken their blood pressure and checked their pulse rate in the midst of the episode.
The symptoms tend to be transient and resolve quickly. Should there be concern that the vital signs will change with position, the health care practitioner will take the blood pressure in both lying and standing positions and look for changes.
According to the American Academy of Neurology, the formal diagnosis of orthostatic hypotension requires a 20mm drop in systolic blood pressure or a 10mm drop in diastolic blood pressure within three minutes of standing. Often there is an associated increase in the heart rate, especially if dehydration or bleeding is the cause (if the patient is taking a beta blocker, the heart rate may not be able to respond with an increase).
Blood tests may be ordered to look for the underlying cause. These may include a red blood cell count (CBC) to access for anemia or bleeding. Electrolytes may be checked, especially if there has been a history of fluid loss through vomiting or diarrhea, since sodium and potassium abnormalities may be an issue. Kidney function may be assessed.
If the physical examination reveals concern about the heart, an electrocardiogram (EKG) may be done to evaluate electrical conduction and heart rhythm. An echocardiogram or ultrasound of the heart may be ordered to evaluate the heart valves and assess the function of the heart muscle. A stress test may be considered if there is concern about coronary artery disease.
A heads-up tilt table test may be ordered if the symptoms of orthostatic hypotension continue to recur but it has been difficult to document abnormalities in blood pressure readings. During the test, the patient is strapped flat on a table, and as the table gradually is tilted to a 70 or 80 degree angle, continuous blood pressure and heart rate readings are taken. The patient may be left on the table for more than 10 minutes to look for the delayed changes seen in postural orthostatic tachycardia syndrome.
For many patients, the diagnosis may be made based upon the history and physical examination, and no further testing may be needed.
What is the treatment for orthostatic hypotension?
The treatment for orthostatic hypotension depends upon the underlying diagnosis. If the cause is dehydration, then fluid replacement will resolve the symptoms. If it is due to medication, then an adjustment of the dose or change in the type of medicine taken may be required.
Compression stockings may be considered to help prevent fluid from pooling in the legs when a person is sitting or lying down. This allows for more blood flow to be available to the brain when changes in position occur.
Medications may be of use, again depending upon the underlying cause of the orthostatic hypotension. For those who are otherwise healthy and have no specific illness that must be treated, increased salt and fluid intake may be recommended. Caffeine and nonsteroidal antiinflammatory medications for example, ibuprofen may also be suggested.
Some patients may be a candidate for fludrocortisone (Florinef) to increase the volume of fluid in the blood vessels. Fludrocortisone is an adrenergic (adrenaline-mimicking) drug, which stimulates the sympathetic nervous system. This medication does have significant side effects, including lowering magnesium and potassium levels in the blood, headache, swelling, and weight gain.
Learn more about: Florinef
What are the complications of orthostatic hypotension?
Falling is the most important complication of orthostatic hypotension. Most often, the symptoms are transient and self- limiting, giving the patient a chance to sit down, but when the drop in blood pressure causes syncope (fainting) or near syncope, it is the trauma that is sustained in the fall that causes the most damage.
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Pregnancy is associated with orthostatic hypotension. As the pregnancy progresses, the volume of the circulatory system expands and blood pressure tends to fall. This may lead to lightheadedness when standing quickly. Blood pressure levels return to normal after delivery.
Excessive sweating due to physical exertion and exposure to heat are risk factors and potential causes of dehydration and symptoms of orthostatic hypotension. Patients who have other risk factors to develop orthostatic hypotension have an increased risk if they become even mildly dehydrated.
Chronic alcohol use and drug abuse are also risk factors for developing symptoms of orthostatic hypotension.
Source: http://www.rxlist.com
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