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Current Hypertension Reports Aug 2013Orthostatic hypotension is a condition commonly affecting the elderly and is often accompanied by disabling presyncopal symptoms, syncope and impaired quality of life.... (Review)
Review
Orthostatic hypotension is a condition commonly affecting the elderly and is often accompanied by disabling presyncopal symptoms, syncope and impaired quality of life. The pathophysiology of orthostatic hypotension is linked to abnormal blood pressure regulatory mechanisms and autonomic insufficiency. As part of its diagnostic evaluation, a comprehensive history and medical examination focused on detecting symptoms and physical findings of autonomic neuropathy should be performed. In individuals with substantial falls in blood pressure upon standing, autonomic function tests are recommended to detect impairment of autonomic reflexes. Treatment should always follow a stepwise approach with initial use of nonpharmacologic interventions including avoidance of hypotensive medications, high-salt diet and physical counter maneuvers. If these measures are not sufficient, medications such as fludrocortisone and midodrine can be added. The goals of treatment are to improve symptoms and to make the patient as ambulatory as possible instead of targeting arbitrary blood pressure values.
Topics: Aging; Blood Pressure; Blood Pressure Determination; Humans; Hypertension; Hypotension, Orthostatic; Syncope
PubMed: 23832761
DOI: 10.1007/s11906-013-0362-3 -
Journal of the American Society of... 2012Orthostatic hypotension (OH) is strongly age-dependent, with a prevalence ranging from 5% to 11% in middle age to 30% or higher in the elderly. It is also closely... (Review)
Review
Orthostatic hypotension (OH) is strongly age-dependent, with a prevalence ranging from 5% to 11% in middle age to 30% or higher in the elderly. It is also closely associated with other common chronic diseases, including hypertension, congestive heart failure, diabetes mellitus, and Parkinson's disease. Most studies of OH have been performed in population cohorts or elderly residents of extended care facilities, but in this review, we draw attention to a problem little studied to date: OH in hospitalized patients. The prevalence of OH in all hospitalized patients is not known because most studies have included only older individuals with multiple comorbid diseases, but in some settings as many as 60% of hospitalized adults have postural hypotension. Hospitalized patients are particularly vulnerable to the consequences of OH, particularly falls, because postural blood pressure (BP) regulation may be disturbed by many common acute illnesses as well as by bed rest and drug treatment. The temporal course of OH in hospitalized patients is uncertain, both because the reproducibility of OH is poor and because conditions affecting postural BP regulation may vary during hospitalization. Finally, OH during hospitalization often persists after discharge, where, in addition to creating an ongoing risk of falls and syncope, it is strongly associated with risk of incident cardiovascular complications, including myocardial infarction, heart failure, stroke, and all-cause mortality. Because OH is a common, easily diagnosable, remediable condition with important clinical implications, we encourage caregivers to monitor postural BP change in patients throughout hospitalization.
Topics: Adult; Aged; Antihypertensive Agents; Female; Hospitalization; Humans; Hypotension, Orthostatic; Male; Middle Aged; Prevalence; Risk Factors
PubMed: 22099697
DOI: 10.1016/j.jash.2011.08.008 -
American Journal of Hospital Pharmacy Mar 1994The pathogenesis, clinical manifestations, and management of orthostatic hypotension (OH) are reviewed. OH is a decline in blood pressure that occurs when one moves from... (Review)
Review
The pathogenesis, clinical manifestations, and management of orthostatic hypotension (OH) are reviewed. OH is a decline in blood pressure that occurs when one moves from a lying to a standing position that results in symptoms of cerebral hypoperfusion, most commonly lightheadedness and syncope. The disorder may result from primary autonomic disorders, such as Shy-Drager syndrome; reversible nonautonomic causes, such as reduced blood volume; underlying diseases, such as diabetes mellitus; and drugs. Elderly people are predisposed to OH. The diagnosis of OH is based on the documentation of postural hypotension accompanied by symptoms of cerebral ischemia. The goal of therapy is to relieve symptoms. Nonpharmacologic approaches are preferred and include increasing sodium intake, avoiding rapid postural changes, and wearing elastic garments. OH is difficult to treat pharmacologically because of varying responses and adverse effects. The drug of choice for all types of OH is fludrocortisone acetate, although caution must be used in patients with congestive heart failure. Prostaglandin synthetase inhibitors can also be used for all types of OH but have had more limited success. Sympathomimetics with or without monoamine oxidase inhibitors, beta-adrenergic antagonists, and ergot alkaloids should be administered only to patients with certain types of OH, and patients must be monitored closely. Clonidine, midodrine, yohimbine, octreotide, dopamine antagonists, desmopressin, and epoetin alfa have not been well studied and should be limited to patients with severe, refractory disease. Although no uniformly effective treatment regimen exists, OH can often be adequately managed with a combination of nondrug and drug therapies.
Topics: Humans; Hypotension, Orthostatic
PubMed: 8203384
DOI: No ID Found -
The Western Journal of Medicine Aug 1985
Topics: Humans; Hypotension, Orthostatic
PubMed: 4036127
DOI: No ID Found -
American Family Physician Sep 2011Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of... (Review)
Review
Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Less common symptoms include syncope, dyspnea, chest pain, and neck and shoulder pain. Causes include dehydration or blood loss; disorders of the neurologic, cardiovascular, or endocrine systems; and several classes of medications. Evaluation of suspected orthostatic hypotension begins by identifying reversible causes and underlying associated medical conditions. Head-up tilt-table testing can aid in confirming a diagnosis of suspected orthostatic hypotension when standard orthostatic vital signs are nondiagnostic; it also can aid in assessing treatment response in patients with an autonomic disorder. Goals of treatment involve improving hypotension without excessive supine hypertension, relieving orthostatic symptoms, and improving standing time. Treatment includes correcting reversible causes and discontinuing responsible medications, when possible. Nonpharmacologic treatment should be offered to all patients. For patients who do not respond adequately to nonpharmacologic treatment, fludrocortisone, midodrine, and pyridostigmine are pharmacologic therapies proven to be beneficial.
Topics: Autonomic Nervous System Diseases; Blood Pressure; Exercise Therapy; Humans; Hypotension, Orthostatic; Syncope; Vasoconstrictor Agents
PubMed: 21888303
DOI: No ID Found -
Postgraduate Medicine 2015In response to a change in posture from supine or sitting to standing, autonomic reflexes normally maintain blood pressure (BP) by selective increases in arteriovenous... (Review)
Review
In response to a change in posture from supine or sitting to standing, autonomic reflexes normally maintain blood pressure (BP) by selective increases in arteriovenous resistance and by increased cardiac output, ensuring continued perfusion of the central nervous system. In neurogenic orthostatic hypotension (NOH), inadequate vasoconstriction and cardiac output cause BP to drop excessively, resulting in inadequate perfusion, with predictable symptoms such as dizziness, lightheadedness and falls. The condition may represent a central failure of baroreceptor signals to modulate cardiovascular function, a peripheral failure of norepinephrine release from cardiovascular sympathetic nerve endings, or both. Symptomatic patients may benefit from both non-pharmacologic and pharmacologic interventions. Among the latter, two pressor agents have been approved by the US Food and Drug Administration: the sympathomimetic prodrug midodrine, approved in 1996 for symptomatic orthostatic hypotension, and the norepinephrine prodrug droxidopa, approved in 2014, which is indicated for the treatment of symptomatic neurogenic orthostatic hypotension caused by primary autonomic failure (Parkinson's disease, multiple system atrophy and pure autonomic failure). A wide variety of off-label options also have been described (e.g. the synthetic mineralocorticoid fludrocortisone). Because pressor agents may promote supine hypertension, NOH management requires monitoring of supine BP and also lifestyle measures to minimize supine BP increases (e.g. head-of-bed elevation). However, NOH has been associated with cognitive impairment and increases a patient's risk of syncope and falls, with the potential for serious consequences. Hence, concerns about supine hypertension - for which the long-term prognosis in patients with NOH is yet to be established - must sometimes be balanced by the need to address a patient's immediate risks.
Topics: Accidental Falls; Aged; Aged, 80 and over; Autonomic Nervous System Diseases; Disease Management; Droxidopa; Female; Humans; Hypotension, Orthostatic; Male; Midodrine; Vasoconstrictor Agents
PubMed: 26012731
DOI: 10.1080/00325481.2015.1050340 -
The Netherlands Journal of Medicine Feb 2014Orthostatic hypotension is common, especially in the elderly, and it is strongly associated with discomfort and falls. Physicians may sometimes prescribe compression... (Review)
Review
AIM
Orthostatic hypotension is common, especially in the elderly, and it is strongly associated with discomfort and falls. Physicians may sometimes prescribe compression therapy, but the beneficial effect of this treatment in orthostatic hypotension is unclear. The aim of this review was to summarise all available evidence on the effect of four different levels of compression therapy in the treatment of orthostatic hypotension: knee-length, thigh-length, full-length and abdominal compression only.
METHODS
A systematic search was performed in PubMed, Embase and Cochrane databases.
RESULTS
A literature search identified 1232 reports; 11 publications were selected for inclusion in this review. The quality of studies was heterogenous and generally poor. Full length compression (lower limbs and abdomen) and compression of solely the abdomen were found to be superior to knee-length and thigh-length compression. Both significantly reduced the fall in systolic blood pressure after postural change. Symptoms of orthostatic hypotension experienced by patients were improved the most by full-length compression.
CONCLUSIONS
When other interventions fail to ameliorate symptoms, compression therapy can be considered. This review demonstrates that compression treatment should include the abdomen as this has the greatest beneficial effect. However, this review also displays the paucity of evidence for compression therapy for patients with orthostatic hypotension, and further investigation is certainly warranted.
Topics: Blood Pressure; Compression Bandages; Humans; Hypotension, Orthostatic; Treatment Outcome
PubMed: 24659590
DOI: No ID Found -
American Journal of Hypertension Mar 2006Hypertension specialists are consulted regarding orthostatic hypotension (OH) or the combination of OH with supine hypertension. These clinical presentations are often... (Review)
Review
Hypertension specialists are consulted regarding orthostatic hypotension (OH) or the combination of OH with supine hypertension. These clinical presentations are often associated with a variety of underlying autonomic disorders. A comprehensive medical history and clinical examination with attention to autonomic signs and the neurological system may suggest the possible etiology or a differential diagnosis. At times, drug therapy for hypertension or other diseases such as Parkinson's is temporally associated with the onset of OH. At other times, no definitive association can be made. Most hypertension specialists can initiate basic evaluation and treatment. Treatment approaches to OH must be targeted primarily to alleviate symptoms of cerebral hypoperfusion and also be cognizant of supine hypertension. Several lifestyle and drug therapies can ameliorate symptoms of OH. Short-acting antihypertensive therapy may be useful in controlling nocturnal supine hypertension.
Topics: Autonomic Nervous System Diseases; Blood Pressure Monitoring, Ambulatory; Humans; Hypertension; Hypotension, Orthostatic; Supine Position
PubMed: 16500521
DOI: 10.1016/j.amjhyper.2005.09.019 -
Postgraduate Medical Journal Jan 2008Orthostatic hypotension (OH) is a frequently encountered problem affecting nearly 30% of the population aged more than 60 years. It can result from neurological and... (Review)
Review
Orthostatic hypotension (OH) is a frequently encountered problem affecting nearly 30% of the population aged more than 60 years. It can result from neurological and non-neurological derangements which compromise the perfusion of the brain in an erect posture. Neurogenic OH is a manifestation of autonomic failure. It is an important cause of recurrent falls in the elderly, syncopal events and also has been shown to be associated with increased long term mortality from vascular and non-vascular causes. This review will discuss the pathophysiology, aetiology, clinical features and management of neurogenic OH and its differentiation from OH caused by non-neurological causes at each step. A clinician should primarily look for any reversible causes in a patient with neurogenic OH and should not forget that treatment is aimed at restoring the functioning capability of the patient rather than normotension. Co-existent supine hypertension in some patients should be taken into account while treating them.
Topics: Accidental Falls; Aged; Humans; Hypotension, Orthostatic; Middle Aged; Posture; Practice Guidelines as Topic; Surveys and Questionnaires
PubMed: 18230746
DOI: 10.1136/pgmj.2007.062075 -
Hypertension (Dallas, Tex. : 1979) Aug 1986
Topics: Adult; Bed Rest; Blood Circulation; Female; Hemodynamics; Humans; Hypotension, Orthostatic; Mitral Valve Prolapse; Physical Exertion; Recurrence; Rest; Sympathetic Nervous System
PubMed: 3733216
DOI: 10.1161/01.hyp.8.8.722