Orthostatic hypotension

Česká verzia

Authors: Z. Bartošová; B. Krahulec
Authors place of work: Prednosta: doc. MUDr. Ľudovít Gašpar, CSc. ; II. interná klinika UNB a LFUK, Bratislava
Published in the journal: Prakt. Lék. 2011; 91(9): 517-521
Category: Reviews

Summary

Orthostatic hypotension (OH), defined as a reduction of systolic blood pressure of at least 20 mm Hg and/or diastolic blood pressure of at least 10 mm Hg within 3 minutes after standing up or while using a head-up tilt table (so called head-up tilt test), is a common finding in a clinical practice, especially in elderly patients. Its presence is associated with a significantly higher morbidity and mortality.

There could be either functional causes of OH e.g. due to medication or states of volume depletion or neurogenic causes that result from lesions of afferent, central or efferent pathways of blood pressure control in autonomic nervous system dysfunction.

Patients with OH could be asymptomatic or manifest symptoms such as dizziness, presyncope and weakness with a higher risk of falls associated with syncope that impair the quality of life of such patient.

The diagnostic evaluation requires a precise blood pressure measurement during standing up or head-up tilt test, taking a history focusing on other possible symptoms of autonomic neuropathy and secondary causes of OH and laboratory and imaging studies with regard to a specific patient.

The aim of the treatment in case of symptomatic patient is to improve the quality of life and minimize the impeding symptoms as much as possible, not to achieve the arbitrary blood pressure. This could be achieved first of all by nonpharmacological approach together with avoidance of potentially reversible causes such as hypotensive medications. In case of failure we step up to the pharmacological agents such as midodrin, 9-α-fluorohydrocortison, ephedrine or nonsteroidal anti-inflammatory drugs.

Key words:
orthostatic hypotension, functional and neurogenic causes, autonomic neuropathy, blood pressure measurement, head-up tilt test.

Zdroje

1. Ziegler, M. Postural hypotension. Annu. Rev. Med. 1980, 31, p. 239-245

2. Krahulec, B., Bartošová, Z. Artériová hypertenzia spojená s ortostatickou hypotenziou. Vnitř. Lék. 2010, 56(9), p. 951-954.

3. Weber, M.A., Wenger, N.K., Scheidt, S. Focus on heart failure and other age-related cardiovascular conditions. Am. J. Geriatr. Cardiol. 2005, 14 p. 221-223.

4. Fedorowski, A., Stavenow, L., Hedblad, B. et al. Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project) European Heart Journal 2010, 31, p. 85-91

5. Gupta, V., Lipsitz, L.A. Orthostatic hypotension in the elderly: diagnosis and treatment. Am. J. Med. 2007, 120(10), p. 841-847.

6. Raiha, I., Luutonen, S., Piha, J. et al. Prevalence, predisposing factors and prognostic importance of postural hypotension. Arch. Intern. Med. 1995, 155 p. 930-935.

7. Luukinen. H-, Koski. K-, Laippala. P., Airaksinen. K.E. Orthostatic hypotension and the risk of myocardial infarction in the home-dwelling elderly. J. Intern. Med. 2004, 255, p. 486-493.

8. Low, P.A. Postural hypotension and anhidrosis. In: Veves A, Malik R. Contemporary Diabetes: Diabetic Neuropathy: Clinical Management. Totowa, New York, Humana Press Inc., 2007, p. 413-432.

9. Wieling, W., Krediet, C.T., van Dijk, N. et al. Initial orthostatic hypotension: review of a forgotten condition. Clin. Sci. (Lond) 2007, 112, p. 157-65.

10. Gibbons, C.H., Freeman, R. Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance. Neurology 2006, 67, p. 28-32.

11. Mader, S.L., Josephson, K.R., Rubenstein, L.Z. Low prevalence of orthostatic hypotension among community-dwelling elderly. JAMA 1987, 258, p. 1511-1514.

12. Weiss, A., Grossman, E., Beloosesky, Y., Grinblat, J. Orthostatic hypotension in acute geriatric ward: is it a consistent finding? Arch. Intern. Med. 2002, 162, p. 2369–2374.

13. Lipsitz, L.A. Orthostatic hypotension in elderly. N. Engl. J. Med. 1989, 321, p. 952-957.

14. Mader, S.L. Orthostatic hypotension. Geriatric Medicine 1989, 73(6), p. 1337-1349.

15. Izzo, J.L., Taylor, A.A. The sympathetic nervous system and baroreflexes in hypertension and hypotension. Current Hypertension Reports 1999, 3, p. 254-263.

16. Eckberg, D.L., Sleight, P. (1992). Human baroreflexes in health and disease. Oxford University Press, Oxford.

17. Carvalho, M.J., van Den Meiracker, A.H., Boomsma, F. et al. Diurnal blood pressure variation in progressive autonomic failure. Hypertension 2000, 35, p. 892-897.

18. Smit, A.A.J., Halliwill, J.R., Low, P.A. et al. Pathophysiological basis of orthostatic hypotension in autonomic failure. Journal of Physiology 1999, 519, p. 1-10.

19. Wieling, W., Karemaker, J.M. Measurement of heart rate and blood pressure to evaluate disturbances in neurocardiovascular control. In: Mathias CJ, Bannister R. Autonomic failure. New York, Oxford University Press, 1999.

20. Sancho, J.R., Burton, J., Barger, A.C. & Haber, E. The role of the renin-angiotensin-aldosterone system in cardiovascular homeostasis in normal human subjects. Circulation 1976, 53, p. 400–405.

21. Cryer, P.E., Silverberg, A.B., Santiago, J.V. et al. Plasma catecholamines in diabetes: the syndromes of hypoadrenergic and hyperadrenergic postural hypotension. Am. J. Med. 1978, 64, p. 407-416.

22. Freeman, R. Neurogenic Orthostatic Hypotension. New England Journal of Medicine 2008, 358, p. 615-624.

23. Bradbury, S., Eggleston, C. Postural hypotension: a report of three cases. Am. Heart J. 1925, 1, p. 73-86.

24. Robertson, D., Hollister, A.S., Biaggioni, I. et al. The diagnosis and treatment of baroreflex failure. N. Engl. J. Med. 1993, 329, p. 1449-1455.

25. Schatz, I.J. Orthostatic hypotension. Functional and Neurogenic Causes. Arch. Intern. Med. 1984, 144, p. 773-777.

26. Mathias, C.J., Bannister, R. Investigation of autonomic disorders. In: Mathias CJ, Bannister R. Autonomic failure. New York, Oxford University Press, 1999.

27. Low, P.A, Opfer-Gehrking, T.L., McPhee, B.R. Prospective evaluation of clinical characteristics of orthostatic hypotension. Mayo Clin. Proc. 1995, 70, p. 617-622.

28. Low, P.A. Postural hypotension and anhidrosis. In: Veves A, Malik R. Contemporary Diabetes: Diabetic Neuropathy: Clinical Management. Totowa, New York, Humana Press Inc., 2007, p. 413-432.

29. Kochar, M.S. Management of postural hypotension. Curr. Hypert. Reports 2000, 2, p. 457-462.

30. Schatz, I.J. Orthostatic hypotension: Clinical diagnosis, testing and treatment. Arch. Int. Med. 1984, 144, p. 1037-1041.

31. Bannister, R., Mathias, C.J. Management of postural hypotension. In: Mathias CJ, Bannister, R. Autonomic failure. New York, Oxford University Press, 1999.

32. Low, P.A., Singer, W. Update on management of neurogenic orthostatic hypotension. Lancet Neurol. 2008, 7, p. 451-458.

33. Gupta, V., Lispitz, L.A. Orthostatic hypotension in the elderly: diagnosis and treatment. A. J. Med. 2007, 120, p. 841-847.

34. Low, P.A., Singer W. Update on management of neurogenic orthostatic hypotension. Lancet Neurol 2008, 7, p. 451-458.

35. Low, P.A., Gilden, J.L., Freeman, R. et al. Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension: a randomized, double-blind multicenter study. JAMA 1997, 277, p. 1046-1051.

36. Fouad-Tarazi, F.M., Okabe, M., Goren, H. Alpha sympathomimetic treatment of autonomic insufficiency with orthostatic hypotension. Am. J. Med. 1995, 99, p. 604-610.

37. Hoeldtke, R.D., Streeten DH. Treatment of orthostatic hypotension with erytropoetin. N. Engl. J. Med. 1993, 329, p. 611-615.