Orthostatic Hypotension

History

• Living Situation
  • Independent living: 5% prevalence
  • Nursing Home: 70% prevalence
• Food ingestion
  • Orthostatic hypotension worsens with large meals (high carbs) and EtOH
    • Pooling of blood in the splanchnic circulation
    • Vasodilatation from insulin and vasoactive peptides
• Hydration status
  • Usually worse with dehydration or in the morning

Diagnosis

📝 the diagnosis is hemodynamic and NOT based on symptoms

• Symptomatic postural decrease in BP
  • SBP ≥ 20 mmHg or DBP ≥ 10 mmHg (usually within 3 minutes)
• Diagnosis made whether symptomatic or asymptomatic
• Closely related to changes in position
  • Lying → Sitting
  • Sitting → Standing
• Time Frame of Symptom onset
  • Within 15 seconds of standing → Initial OH (recovery in < 1 minute)
    • tends to occur more often in younger patients, but it may also occur in elderly patients¹
    • more pronounced on active standing than on passive tilt¹
      • 
  • Within 3 minutes of standing → Classic OH
  • After 3 minutes of standing → Delayed OH
• 📝 Typically the HR increment is minimal ²

Etiologies

Non-Reversible

• Secondary Autonomic Failure / Peripheral neuropathy
  • Diabetes
    • Severity and duration of diabetes does not correlate to severity of OH
  • Alcoholism
  • Chemotherapy
  • HIV
  • Paraneoplastic syndromes (small cell lung CA most commonly)
  • Amyloidosis
  • B12 deficiency (reversible)
  • Guillain Barre (recovers over time)
  • Vasculitis
• Primary Autonomic Failure / Neurodegenerative disorders
  • ~27% of moderate-severe OH have primary autonomic failure
  • Parkinson disease (20 - 60% prevalence of OH)?
    • Rigidity, resting tremor, shuffling gait
    • Responds to levodopa
  • Lewy body dementia
    • Parkinsonism with dementia, cognitive impairments, usually more severe OH
  • Multiple system atrophy
    • CNS: Parkinsonian and cerebellar variants, with urinary incontinence and constipation, ED
    • Does not respond to levodopa (usually)
  • Pure autonomic failure (Bradbury-Eggleston)
    • PNS: Diffuse autonomic issues with slow heart rate, urinary incontinence, ED, difficulty sweating

Management

• Liberalize salt and fluid
  • Consider fluid bolus
• Compression hose (higher is better)
• Counterpressure maneuvers, e.g. leg crossing, limb and/or abdominal contraction, squatting
  • 
• Stop offending medication(s)
  • Commonly used medications (hidden sympatholytics) can worsen orthostatic hypotension (e.g. tizanidine, trazodone, tamsulosin).
• Consider fludrocortisone (0.1 mg daily)
• Consider midodrine (5 mg TID)
• Consider droxidopa (100 mg TID)
• refer to EP or Autonomic Neurology
• To read:
  • ³
  • ⁴

Footnotes

1. Freeman, Roy, et al. “Orthostatic Hypotension.” Journal of the American College of Cardiology, vol. 72, no. 11, Sept. 2018, pp. 1294–309. DOI.org (Crossref), https://doi.org/10.1016/j.jacc.2018.05.079. ↩ ↩²

2. Bryarly M, Phillips LT, Fu Q, Vernino S, Levine BD. Postural Orthostatic Tachycardia Syndrome: JACC Focus Seminar. J Am Coll Cardiol. 2019 Mar 19;73(10):1207-1228. doi: 10.1016/j.jacc.2018.11.059. PMID: 30871704. ↩

3. Park JW, Okamoto LE, Shibao CA, Biaggioni I. Pharmacologic treatment of orthostatic hypotension. Auton Neurosci 2020;229:doi: 10.1016/j.autneu.2020.102721. ↩

4. Gibbons CH, Schmidt P, Biaggioni I, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol 2017;264:1567-82. ↩