Essay Example on Orthostatic hypotension is defined as an excessive fall in blood pressure









Orthostatic hypotension is defined as an excessive fall in blood pressure when an upright position is assumed This excessive fall in blood pressure is greater than 20mmHg systolic or greater than10mmHg diastolic or both After this fall in blood pressure the patient may experience symptoms such as lightheadedness blurred vision confusion or feeling pre syncopal On an extreme end patients may actually have syncopal episodes or even seizures Higginson 2016 Typically when a person stands up blood pools in the lower extremities and trunk Up to 1L of blood may pool which then decreases the venous return to the heart There are baroreceptors in the aortic arch and carotid bodies that activate the sympathetic nervous system which helps the blood pressure quickly rise back to normal levels This activation also causes an increase in cardiac contractility and heart rate and increases peripheral vascular resistance These responses increase peripheral blood pressure and increase the cardiac output Finally there is vagal inhibition which inhibits slowing down of the heart rate further increasing the heart rate and thus cardiac output Therefore upon standing there are many mechanisms in place to ensure the blood pressure does not drop significantly Higginson 2016 Normally systolic blood pressure will fall 5 10mmHg diastolic pressure will rise 5 10mmHg and heart rate will increase by 10 25 beats minute Kaufmann 2015 Orthostatic hypotension occurs when one of these back up mechanisms fail In the elderly it has been found that they have decreased baroreceptor sensitivity This decreased sensitivity will then cause a decrease in the response of the sympathetic nervous system and decreased inhibition of the vagal nerve This then allows the systolic and diastolic blood pressure to drop without an increase in heart rate 

Other causes are neurodegenerative diseases such as Parkinson s and Lewy body dementia and autonomic neuropathy Another cause of orthostatic hypotension is the use of medications such as sympathetic blockers antiparkinsonism drugs PDE 5 inhibitors diuretics muscle relaxers and antipsychotics Kaufmann 2015 With diuretics volume depletion causes a decreased blood pressure and the body may not be able to fully compensate for the further decrease in blood pressure upon standing These remaining medications may influence autonomic activity and peripheral vascular tone Typically the patient will present with complaints of feeling lightheaded dizzy or having darkening vision upon standing up quickly or bending over due to hypoperfusion In severe cases the patient may experience syncopal episodes or seizures The severity of the symptoms is highly patient dependent and may vary from asymptomatic to syncope Kaufmann 2015 Upon physical exam orthostatic vitals must be taken The best way to determine if a patient is experiencing orthostatic hypotension is to first take the blood pressure and pulse while the patient is supine It is also important that an EKG and blood glucose are obtained to rule out cardiac components or hypoglycemia The best way to determine the course and treatment options for orthostatic hypotension are to first determine the patients cause of the orthostatic hypotension 

Once the cause is identified treatment will most likely resolve the orthostatic hypotension Some non drug treatment options are rising slowly staying hydrated avoiding alcohol Patient should also exercise in order to promote venous blood return Compression stockings may also help increase the venous return to the heart With severe cases patient s may require inflatable aviator type anti gravity suits Higginson 2016 These treatment options pose minimal risk to the patient Patient may also increase sodium and water intake to help increase the intravascular volume The problem with this approach is the potential to exacerbate heart failure and edema Medications may be used to treat orthostatic hypotension Fludrocortisone may be used to help with fluid resorption by the kidney but poses the risk of heart failure hypokalemia and hypertension Midodrine may also be used which is an alpha agonist and uses arterial and venous constriction thus increasing the peripheral vascular resistance and increasing the blood pressure This medication cannot be used if the patient suffers from coronary artery disease or peripheral arterial disease because it may exacerbate these conditions

NSAIDs are another treatment option because they inhibit vasodilation thus increasing the peripheral vascular resistance NSAIDs must be used with caution because they may cause peptic ulcers hyperkalemia and worsen cardiac co morbidities Higginson 2016 If the orthostatic hypotension is caused by a medication the best treatment option is to decrease the dose or discontinue that medication and prescribe the patient on a different medication According to uptodate a history of orthostatic hypotension has been shown to be a risk factor for cardiovascular and all cause mortality This is most likely due to the underlying conditions though and not specifically due to orthostatic hypotension Other studies have shown a link between orthostatic hypotension and future atrial fibrillation and congestive heart failure In the elderly specifically the lightheadedness from orthostatic hypotension may cause the patient to fall leading to fractures or hemorrhages which may be life threatening Some studies have shown cognitive decline in patients with orthostatic hypotension which is thought to be due to cerebral hypoperfusion Finally orthostatic hypotension may lead to a decreased quality of life because the patient is afraid to stand up this could then lead to anxiety depression or suicidal ideation

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