Orthostatic hypotension

Background

  • More common in older patients
  • Symptomatic orthostasis is clinically much more important than actual change in vitals
    • Classically, drop in SBP ≥20 mm Hg or increase in HR ≥ 30 bpm when moving from lying to standing
    • Studies show that orthostatic vitals common at baseline health, and not necessarily abnormal in moderate volume loss [1][2][3]

Clinical Features

  • Sudden postural changes resulting in cerebral hypoperfusion
  • Weakness, lightheadedness, visual blurring
  • Occasionally syncope

Differential Diagnosis

  • Autonomic dysfunction
    • Parkinson Disease
    • Lewy Body Dementia
    • Shy-Drager Syndrome
    • Diabetes
  • Aging
  • Volume depletion
    • Diuretics
    • Hemorrhage
    • Vomiting/ Diarrhea
  • Medications
  • Alcohol use
  • Syncope
  • Seizure
  • Postural tachycardia syndrome (POTS)

Evaluation

  • Review medication list
  • History of potential volume loss
  • CBC (anemia)
  • BMP (electrolytes, BUN, Cr, glucose)
  • EKG

Management

  • Address the underlying cause
    • Fluids, blood transfusion when appropriate
    • Consider discontinuing at risk medications

Disposition

Depends on patient's risk, etiology of orthostasis, secondary complications such as worsening hypovolemia, potential for falls

See Also

External Links

References

  1. Ooi WL, Barrett S, Hossain M, Kelley-Gagnon M, Lipsitz LA. Patterns of Orthostatic Blood Pressure Change and Their Clinical Correlates in a Frail, Elderly Population. JAMA. 1997;277(16):1299–1304. doi:10.1001/jama.1997.03540400049030
  2. Skinner, J. E., Driscoll, S. W., Porter, C. B. J., Brands, C. K., Pianosi, P. T., Kuntz, N. L., Nelson, D. E., Burkhardt, B. E., Bryant, S. C., & Fischer, P. R. (2010). Orthostatic heart rate and blood pressure in adolescents: Reference ranges. Journal of Child Neurology, 25(10), 1210-1215. https://doi.org/10.1177/0883073809359539
  3. McGee S, Abernethy III WB, Simel DL. Is This Patient Hypovolemic? JAMA. 1999;281(11):1022–1029. doi:10.1001/jama.281.11.1022
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