Orthostatic hypotension: Difference between revisions

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==Background==
==Background==
* More common in older patients
* More common in older patients
* Symptomatic orthostasis more important than actual change in vitals
* 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
** 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 in, and not necessarily abnormal in acutely ill <ref>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</ref><ref>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</ref>
** Studies show that orthostatic vitals common at baseline health, and not necessarily abnormal in moderate volume loss <ref>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</ref><ref>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</ref><ref>McGee S, Abernethy III WB, Simel DL. Is This Patient Hypovolemic? JAMA. 1999;281(11):1022–1029. doi:10.1001/jama.281.11.1022</ref>
 


==Clinical Features==
==Clinical Features==
* Sudden postural changes resulting in cerebral hypoperfusion
* Sudden postural changes resulting in cerebral hypoperfusion
* Weakness, lightheadedness, visual blurring
* [[Weakness]], lightheadedness, visual blurring
* Occasionally syncope
* Occasionally, [[syncope]]


==Differential Diagnosis==
==Differential Diagnosis==
* Autonomic dysfunction
* Autonomic dysfunction
* Volume depletion
** [[Parkinson's disease]]
** Diuretics
** [[Lewy Body Dementia]]
** Hemorrhage
** Shy-Drager Syndrome
** Vomiting/ Diarrhea
** [[Diabetes]]
* Aging
* [[hypovolemia|Volume depletion]]
** [[Diuretics]]
** [[Hemorrhage]]
** [[Vomiting]]/ [[Diarrhea]]
* Medications
* Medications
** [[Antihypertensives]], antiparkinsonism, [[beta blockers]], vasodilatory drugs
** [[Antihypertensives]], antiparkinsonism, [[beta blockers]], vasodilatory drugs
* Alcohol use
* Alcohol use
* Aging
* [[Syncope]]
* [Syncope]
* [[Seizure]]
* [Seizure]
* Postural tachycardia syndrome (POTS)


==Evaluation==
==Evaluation==
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* CBC (anemia)
* CBC (anemia)
* BMP (electrolytes, BUN, Cr, glucose)
* BMP (electrolytes, BUN, Cr, glucose)
* EKG  
* [[EKG]]


==Management==
==Management==
* Address the underlying cause
* Address the underlying cause
** Fluids, blood transfusion when appropriate
** [[Fluids]], blood [[transfusion]] when appropriate
** Consider discontinuing at risk medications
** Consider discontinuing at risk medications


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


==See Also==
==See Also==
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==References==
==References==
<references/>
<references/>
[[Category:Cardiology]]

Latest revision as of 17:34, 25 October 2020

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

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