Postural Hypotension

Dr. Pushkar Manandhar

DEFINATION
Postural hypotension is defined as a reduction in systolic blood pressure of 20mmHg or more after standing for at least one minute.

Also known as orthostatic hypotension, it is a common problem in older people, affecting 10-33% of them.

NORMAL ANATOMY AND PHYSIOLOGY

Blood pressure is measured in millimeters of mercury (mmHg) and is displayed with two numbers, one over the other, as in 120/80mmHg.
When blood is pumping through the arteries, the systolic pressure is the higher number, when the pressure is greatest on the walls of the arteries.

The lower number is the diastolic pressure, which is the resting phase of the blood pumping cycle.

PATHOPHYSIOLOGY
Hypotension is the condition of having unusually low blood pressure on a regular or semi-regular basis. Hypotension involves blood pressure that is 90/60mmHg. Orthostatic or postural hypotension is low blood pressure that results from standing up abruptly from a sitting or lying position. When an individual stands quickly, both arteries and veins have to contract in order to maintain normal blood pressure in the new position. The process usually occurs automatically, but with postural hypotension, the reflex is defective and the flow of blood to the brain is temporarily reduced or lower.

MANIFESTATIONS
The symptoms may vary from dizziness to syncope, which are both associated with visual disturbances ranging from blurred vision to blackouts Weakness, Angina, Low backache Lethargy One of the most common complaints older patients present with is a history of falls. Other symptoms include confusion and continence problems.

DIAGNOSIS
Diagnosis of postural hypotension involves demonstrating a postural fall in blood pressure after standing. The patients lying and standing blood pressure measurements should be taken, preferably in the morning In a patient who has unexplained syncope and falls, the symptoms need to be reproduced to make a diagnosis. Assessing for the presence of postural hypotension is particularly relevant in older people with a history of falls After eating a meal, the patient may experience a significant fall in blood pressure that may be a symptom of the condition. Again, this can only be diagnosed by measuring the patients standing blood pressure after a meal

MANAGEMENT
Non-pharmacologic Treatments
adequate fluid intake, limit or avoid alcohol and exercise regularly in horizontal position change posture slowly and avoid standing still spend sitting up each day in prolonged bed rest patients Frequent small meal and avoid standing up suddenly. Avoid hot shower and excessive heat Avoid straining during micturition and defecation. Increase salt intake

MANAGEMENT
Pharmacological Treatment
1. Midodrine Sympathomimetic vasoconstrictor , acts directly on resistance vessels. Fludrocortisone Mineralocorticoid , reduce salt loss and expands plasma volume. Dihydroergotamine Sympathomimetic vasoconstrictor may increase venous return without increasing arterial pressure. Erythropoietin Increases hemoglobin and blood volume. Octreotide Direct vasoconstriction and increases cardiac output.

2. 3.

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MANAGEMENT
Pharmacological Treatment
6. Combination Therapy
In severe cases, a combination of midodrine and octreotide

7. Pacemaker Therapy

Prognosis Depends on the underlying cause. Diastolic OH at 1 min and systolic OH at 3 min ,predicts vascular death in older. OH poor prognosis in DM with HT , risk of death is increased.

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