Orthostatic hypotension

For the television science series, see Head Rush (TV series).
Orthostatic hypotension
Classification and external resources
Pronunciation /ˌɔːrθəˈstætɪkˌhaɪpəˈtɛnʃən/
Specialty Cardiology
ICD-10 I95.1
ICD-9-CM 458.0
DiseasesDB 10470
MeSH D007024

Orthostatic hypotension, also known as postural hypotension,[1] orthostasis, and colloquially as head rush or dizzy spell, is a form of low blood pressure in which a person's blood pressure falls when suddenly standing up or stretching. In medical terms, it is defined as a fall in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position.

The symptom is caused by blood pooling in the lower extremities upon a change in body position. It is quite common and can occur briefly in anyone, although it is prevalent in particular among the elderly, and those with low blood pressure.

Signs and symptoms

When orthostatic hypotension is present, the following symptoms can occur after sudden standing or stretching (after sitting):

They are consequences of insufficient blood pressure and cerebral perfusion (blood supply). Occasionally, there may be a feeling of warmth in the head and shoulders for a few seconds after the dizziness subsides. The drop in blood pressure may cause a vasovagal episode to occur.

Causes

Orthostatic hypotension is caused primarily by gravity-induced blood-pooling in the lower extremities, which in turn compromises venous return, resulting in decreased cardiac output and subsequent lowering of arterial pressure. For example, changing from a lying position to standing loses about 700 ml of blood from the thorax, with a decrease in systolic and diastolic blood pressures.[2] The overall effect is an insufficient blood perfusion in the upper part of the body.

Still, the blood pressure does not normally fall very much, because it immediately triggers a vasoconstriction (baroreceptor reflex), pressing the blood up into the body again. (Often, this mechanism is exaggerated and is why diastolic blood pressure is a bit higher when a person is standing up, compared to a person in horizontal position.) Therefore, a secondary factor that causes a greater than normal fall in blood pressure is often required. Such factors include low blood volume, diseases, and medications.

Hypovolemia

Orthostatic hypotension may be caused by low blood volume, resulting from bleeding, the excessive use of diuretics, vasodilators, or other types of drugs, dehydration, or prolonged bed rest. It also occurs in people with anemia.

Diseases

The disorder may be associated with Addison's disease, atherosclerosis (build-up of fatty deposits in the arteries), diabetes, pheochromocytoma, and certain neurological disorders, including multiple system atrophy and other forms of dysautonomia. It is also associated with Ehlers-Danlos syndrome and Anorexia Nervosa. It is also present in many patients with Parkinson's disease resulting from sympathetic denervation of the heart or as a side-effect of dopaminomimetic therapy. This rarely leads to fainting unless the person has developed true autonomic failure or has an unrelated heart problem.

Another disease, dopamine beta hydroxylase deficiency, also thought to be underdiagnosed, causes loss of sympathetic noradrenergic function and is characterized by a low or extremely low levels of norepinephrine, but an excess of dopamine.[3]

Quadriplegics and paraplegics also might experience these symptoms due to multiple systems' inability to maintain a normal blood pressure and blood flow to the upper part of the body.

A study by a Harvard Medical School team found the two sacs in the inner ear, the utricle and the saccule, affect brain blood flow; thus, inner ear problems, which increase with old age, may be involved in orthostatic hypotension.[4]

Medication

Orthostatic hypotension can be a side-effect of certain antidepressants, such as tricyclics[5] or monoamine oxidase inhibitors (MAOIs).[6] Marijuana and tetrahydrocannabinol can on occasion produce marked orthostatic hypotension.[7] Orthostatic hypotension can also be a side effect of Alpha-1 blockers (alpha1 adrenergic blocking agents). Alpha1 blockers inhibit vasoconstriction normally initiated by the baroreceptor reflex upon postural change and the subsequent drop in pressure.[8]

B12 deficiency

Orthostatic hypotension sometimes is a reversible neurological complication of vitamin B12 deficiency.[9]

Harnesses

The use of a safety harness does not contribute to orthostatic hypotension in the event of a fall. This notion is a hypothetical risk which has all but been eliminated due to modern design and safety regulations.[10] If worn properly, a safety harness may safely rescue its user from a fall without any further complications so long as the individual does not remain suspended for prolonged periods of time.[10]

Other factors

Patients prone to orthostatic hypotension are the elderly, post partum mothers, and those having been on bedrest. People suffering from anorexia nervosa and bulimia nervosa often suffer from orthostatic hypotension as a common side-effect. Consuming alcohol may also lead to orthostatic hypotension due to its dehydrating effects.

Diagnosis

There is a simple test for OH that measures the person's blood pressure after lying flat for 5 minutes, then 1 minute after standing, and 3 minutes after standing.[11] Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mmHg and/or in the diastolic blood pressure of at least 10 mmHg between the supine reading and the upright reading. In addition, the heart rate should also be measured for both positions. A significant increase in heart rate from supine to standing may indicate a compensatory effort by the heart to maintain cardiac output or Postural Orthostatic Tachycardia Syndrome (POTS). A tilt table test may also be performed.

Management

Physical measures - Raise the head of the bed by 10 - 20 degree , Arise slowly , in stages from supine to seated to standing. Dorsiflexion of the feet , handgrip isometric , leg crossing / squatting before standing ( all to increase venous return )

Fludrocortisone with high salt diet is the initial treatment of choice with suppliment ageints : NSAID's , Caffeine , erythropoietin ( if anaemic )

The evidence to support treatment is poor. A number of measures have slight evidence to support their use including compression bandages, midodrine, indomethacin, fluoxeitine , Dopamine antagonist : metocloramide , domperidone , MAO inhibitors with tyramine ( can produce severe HTN ) , oxilofrine, potassium chloride, and yohimbine.[12] Midodrine can reduce dizzy spells and faints by about a third, although the quality of the evidence underlying this finding is limited.[13] The main side-effect is piloerection ("goose bumps").[13]

Prognosis

Orthostatic hypotension may cause accidental falls.[14] It is also linked to an increased risk of death, cardiovascular disease, heart failure, and stroke.[15]

See also

References

  1. ↑ "Orthostatic hypotension" at Dorland's Medical Dictionary
  2. ↑ Idiopathic Orthostatic Hypotension and other Autonomic Failure Syndromes at eMedicine
  3. ↑ "Dopamine Beta-Hydroxylase Deficiency". GeneReviews — NCBI Bookshelf.
  4. ↑ "Minute organs in the ear can alter brain blood flow". BBC News. 2009-12-27. Retrieved 2009-12-27.
  5. ↑ Jiang W, Davidson JR. (2005). "Antidepressant therapy in patients with ischemic heart disease". Am Heart J 150 (5): 871–81. doi:10.1016/j.ahj.2005.01.041. PMID 16290952.
  6. ↑ Delini-Stula A, Baier D, Kohnen R, Laux G, Philipp M, Scholz HJ. (1999). "Undesirable blood pressure changes under naturalistic treatment with moclobemide, a reversible MAO-A inhibitor—results of the drug utilization observation studies". Pharmacopsychiatry 32 (2): 61–7. doi:10.1055/s-2007-979193. PMID 10333164.
  7. ↑ Jones RT. (2002). "Cardiovascular system effects of marijuana". J Clin Pharmacol 42 (11 Suppl): 58S–63S. doi:10.1002/j.1552-4604.2002.tb06004.x. PMID 12412837.
  8. ↑ Orthostatic Hypotension at Merck Manual of Diagnosis and Therapy Home Edition
  9. ↑ Beitzkea, Markus; Peter Pfistera; Jürgen Fortinb; Falko Skrabal (2002-04-18). "Autonomic dysfunction and hemodynamics in vitamin B12 deficiency". Autonomic Neuroscience 97 (1): 45–54. doi:10.1016/S1566-0702(01)00393-9. PMID 12036186.
  10. 1 2 Lee C, Porter KM (Apr 2007). "Suspension trauma". Emerg Med J. 24 (4): 237–8. doi:10.1136/emj.2007.046391. PMC 2658225. PMID 17384373.
  11. ↑ "STEADI - Measuring Orthostatic Blood Pressure" (PDF). Centers for Disease Control and Prevention. Retrieved 20 December 2014.
  12. ↑ Logan, IC; Witham, MD (September 2012). "Efficacy of treatments for orthostatic hypotension: a systematic review.". Age and ageing 41 (5): 587–94. doi:10.1093/ageing/afs061. PMID 22591985.
  13. 1 2 Izcovich, A.; Gonzalez Malla, C.; Manzotti, M.; Catalano, H. N.; Guyatt, G. (22 August 2014). "Midodrine for orthostatic hypotension and recurrent reflex syncope: A systematic review". Neurology 83 (13): 1170–1177. doi:10.1212/WNL.0000000000000815. PMID 25150287.
  14. ↑ Romero-Ortuno R, Cogan L, Foran T, Kenny RA, Fan CW (2011). "Continuous noninvasive orthostatic blood pressure measurements and their relationship with orthostatic intolerance, falls, and frailty in older people". J Am Geriatr Soc 59 (4): 655–65. doi:10.1111/j.1532-5415.2011.03352.x. PMID 21438868.
  15. ↑ Ricci, F; Fedorowski, A; Radico, F; Romanello, M; Tatasciore, A; Di Nicola, M; Zimarino, M; De Caterina, R (1 July 2015). "Cardiovascular morbidity and mortality related to orthostatic hypotension: a meta-analysis of prospective observational studies.". European Heart Journal 36 (25): 1609–17. doi:10.1093/eurheartj/ehv093. PMID 25852216.

External links

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