Orthostatic hypotension

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Orthostatic hypotension
Classification and external resources
ICD-10 I95.1
ICD-9 458.0
DiseasesDB 10470
eMedicine ped/2860
MeSH D007024

Orthostatic hypotension, also known as postural hypotension,[1] orthostasis, and colloquially as head rush or dizzy spell, is a form of hypotension in which a person's blood pressure suddenly falls when 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[edit]

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

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[edit]

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 hypovolemia, diseases, and medications.


Hypovolemia[edit]

Orthostatic hypotension may be caused by hypovolemia (a decreased amount of blood in the body), 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[edit]

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. 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 syncope unless the patient has developed true autonomic failure or has an unrelated cardiac 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.

Recently, a common but underdiagnosed condition suspected to be closely related to orthostatic hypotension is spontaneous intracranial hypotension,[citation needed] which results from cerebrospinal fluid leakage. It affects women more than men and peaks at ages between 40 and 50.

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[edit]

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[edit]

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

Harnesses[edit]

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.[11]

Other factors[edit]

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.

Orthostatic hypotension is also associated with Naturopathic treatment and the practice of yoga, when the pressure gradient varies during these practices.

Diagnosis[edit]

There is a simple test for OH that measures the person's blood pressure while seated or reclining at rest, and again upon standing up. 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 from supine to standing may indicate a compensatory effort by the heart to maintain cardiac output.

A tilt table test may also be performed.

Management[edit]

The evidence to support treatment is poor. A number of measures with slight evidence to support their use include: compression bandages, midodrine, indomethacin, oxilofrine, potassium chloride, and yohimbine.[12]

Prognosis[edit]

Orthostatic hypotension may cause accidental falls.[13]

See also[edit]

References[edit]

Notes

  1. ^ "Orthostatic hypotension" at Dorland's Medical Dictionary
  2. ^ http://emedicine.medscape.com/article/1154266-overview
  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. 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. ^ 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. ^ 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. 
  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. ^ 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. 

External links[edit]