HWN Suggests

Determining the causes of postural hypotension

Humans need to maintain continuous intracranial perfusion despite the persistent effect of gravity. In a recent Canadian Family Physician blog, postural hypotension was described as “the missing vital sign.” Postural hypotension is easy to miss and, even when detected, it is challenging to work through the complex differential diagnosis. Often the cause is multifactorial, requiring a systematic approach to assessing and prioritizing contributing factors. The 4D-AID approach (originally 3D-AID2) provides a useful framework...

read full article

Articles of Interest

The Missing Vital Sign – Postural Ones

Postural (orthostatic) hypotension is a common problem in older patients... Diagnosis and treatment can be more difficult than would appear on the surface, especially when patients are taking multiple medications and have co-morbidities.

(Dis)utility of Orthostatics in Volume Depletion

Based on the low overall sensitivity of orthostatic vital sign measurements, they should not be used to influence clinical decision making.

After standing, a fall in blood pressure

Known as orthostatic hypotension, this condition can leave people dizzy and lightheaded. For some, it may also be a harbinger of heart disease.

Determining the causes of postural hypotension

Humans need to maintain continuous intracranial perfusion despite the persistent effect of gravity. In a recent Canadian Family Physician blog, ,postural hypotension was described as “the missing vital sign.”1 Postural hypotension is easy to miss and, even when detected, it is challenging to work through the complex differential diagnosis. Often the cause is multifactorial, requiring a systematic approach to assessing and prioritizing contributing factors.

Diagnosis and treatment of orthostatic hypotension

Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope.

New Horizons in orthostatic hypotension

OH remains common in older people, the new diagnostic criteria address some of the previous uncertainty but evidence concerning withdrawal of antihypertensives is conflicting. Midodrine is now the only licenced medication for OH in the UK, but non-drug therapies remain first line and fludrocortisone may be considered before midodrine. We may see other agents such as droxidopa becoming increasingly used over the coming years.

Orthostatic Hypotension: A Practical Approach

Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of at least 60 degrees during tilt table testing. Symptoms are due to inadequate physiologic compensation and organ hypoperfusion and include headache, lightheadedness, shoulder and neck pain (coat hanger syndrome), visual disturbances, dyspnea, and chest pain. Prevalence of orthostatic hypotension in the community setting is 20% in older adults and 5% in middle-aged adults.

Orthostatic Hypotension: A Practical Approach to Investigation and Management

The maintenance of blood pressure upon the assumption of upright posture depends on rapid cardiovascular adaptations driven primarily by the autonomic nervous system. Failure of these compensatory mechanisms can result in orthostatic hypotension (OH), defined as sustained reduction in systolic blood pressure > 20 mm Hg or diastolic blood pressure > 10 mm Hg within 3 minutes of standing or > 60° head-up tilt. OH is a common finding, particularly in elderly populations, associated with cardiovascular and cerebrovascular morbidity and mortality.

Postural Orthostatic Hypotension (POTS): A Recent Finding in COVID

One increasingly recognized autonomic nervous system (ANS) disorder is postural orthostatic tachycardia syndrome or POTS. It occurs in those recovering from COVID-19, which makes it a perfect example post-infectious, immunity and inflammation (I-Cubed). POTS causes seemingly causes cardiac symptoms such as rapid palpitations, lightheadedness, chest discomfort, and shortness of breath, as well as non-cardiac symptoms including brain fog, headache, nausea, tremulousness, generalized weakness, and blurred or tunnel vision.

Preventing and treating orthostatic hypotension: As easy as A, B, C

Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. Because orthostatic stress varies with circumstances during the day, a patient-oriented approach that emphasizes education and nonpharmacologic strategies is critical.

Still Worthless – Orthostatic Vitals and 30-Day Outcomes

Our Conclusions: Abnormal orthostatic vital signs or symptoms are not associated with an increased risk of adverse outcomes at 30-days. Potential to Impact Current Practice: This is another study demonstrating the disutility of orthostatic vital sign measurements in the ED. Not only are the performance characteristics poor for predicting mild to moderate volume loss, but they also cannot be used to risk stratify for bad outcomes. While there may be select patients that can benefit from obtaining orthostatic vital signs, they should not be routine for elderly patients presenting with syncope or near-syncope. Bottom Line: In this secondary analysis of patients aged ≥ 60 years, abnormal orthostatic vital signs do not predict serious 30-day outcomes and should not be used as a routine assessment in syncope.

The Prevalence of Orthostatic Hypotension: A Systematic Review and Meta-Analysis

OH is very common, affecting one in five community-dwelling older people and almost one in four older people in long-term care. There is great variability in methods used to identify OH.

Treatment of Orthostatic Hypotension In Older Patients: The Geriatric Perspective

Fludrocortisone (florinef) is an oral synthetic mineralocorticoid analog that sensitizes peripheral alpha receptors and expands intravascular volume by increasing renal sodium reabsorption. Consequently fludrocortisone is contraindicated in fluid overload conditions (CHF, ascites, etc.). It also has a pressor effect that treats OH by increasing peripheral vascular resistance.17 It is usually the first choice for most patients with OH.

When blood pressure falls after you stand up

Known as orthostatic hypotension, this condition becomes more common with age and frailty.

When He Stood Up Quickly, He Sometimes Fainted. What Was It?

These filters are supposed to be removed a few months later when the risk of clotting goes down, but many are not removed on schedule. This one had been left in place for more than 15 years. What if, Slief suggested after explaining this history, the filter had done its job and captured clots and they were now blocking the entire vessel? Could that cause his positional hypotension? Centor listened thoughtfully. He’d been a doctor for 45 years and had never seen this. And yet it was an interesting idea. Certainly worth considering.

You Asked: Why Do I Get Dizzy When I Stand Up?

It happens every so often when you get up from your desk, or hop out of bed. You stand up suddenly and are met with a feeling of wooziness. In some cases, your vision gets splotchy, or you have to brace yourself until the dizziness passes—which it always does in a matter of seconds. Experts have a name for this fleeting condition: initial orthostatic hypotension (OH). If you experience it now and then—and research suggests most people do—rest assured that, in most cases, it’s harmless.

Resources

StatPearls

Orthostatic hypotension is defined as a sudden drop in blood pressure upon standing from a sitting or supine position. Clinically, this is diagnosed by a sustained reduction in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of 10 mmHg within three minutes of standing after being supine for five minutes or at a 60-degree angle on the tilt table. This sudden drop in blood pressure is usually secondary to failure of the autonomic reflex, volume depletion, or adverse reaction to a medication.