Orthostatic Hypotension with Supine Hypertension - Department of ...

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Orthostatic Hypotension with Supine Hypertension - Department of ...

75F from home admitted with recurrent

epistaxis

Profile: CAD, TIA, COPD, smoker

Meds: Symbicort, Spiriva, Metoprolol,

Lipitor, Vitamin D, Iron, Multivitamin

2 units pRBCs required for significant

blood loss (HgB 133 68)

Severely deconditioned (no activity x

3/52 or longer)


RFR: symptomatic orthostatic hypotension

Findings on exam:

Supine BP: 153/65

Sitting BP: 116/60

Standing BP: 72/35

Decreased sensation to mid leg bilaterally

HgB 94


Definition: within 3 minutes of standing a

drop in SBP >20 mmHg or DBP >10 mmHg

Prevalence:

› Increases with age

› Up to 55% of geriatric patients affected


Gupta V et al (2007). Orthostatic hypotension in the

elderly: diagnosis and treatment. The American Journal

of Medicine. 120:841-847.


The cause of this patient’s acute

orthostatic hypotension was felt to be

acute blood loss from the epistaxis and

anemia

Other contributing factors:

› Metoprolol

› Physical deconditioning


Non-pharmacologic options:

› Discontinue medications with OH as S/E

› Raise head of bed 20 degrees

› Rise slowly from supine to sitting to standing

› Cross legs while standing

› Compression stockings

› Exercise

› Increase salt and water intake

› Coffee in the morning


Gupta V et al (2007). Orthostatic hypotension in the elderly: diagnosis and treatment. The American Journal of Medicine. 120:841-847.


The patient was advised to implement

the non-pharmacologic treatment

options

Metoprolol was tapered until

discontinued

Fludrocortisone 0.1mg PO daily


Definition: SBP > 150 mmHg or DBP > 90

mmHg while supine with normal seated

and low upright blood pressures

Limited studies on SH, but suggested

mechanism is increased systemic

vascular resistance

Clinical significance of SH unknown; no

longitudinal studies


Prevalence:

• Up to one half of pts with autonomic failure

leading to OH have SH (Jordan & Biaggioni,

2002)

• A study by Ejaz et al. (2007) looking at

ambulatory BP measurements (ABPM)

reported that pts with OH have similar ABPM

findings and 93% had SH (although they

defined SH as BP >120/75)


End-organ damage – LVH, renal

impairment

Case reports of hypertensive

emergencies in SH/OH pts leading to:

› Stroke

› Cerebral hemorrhage

› Papilledema

› Heart failure


Non-pharmacologic:

› Sleep with head of bed elevated 20 to 30

degrees

› Snack before bedtime (~400 kcal) to induce

postprandial hypotension

› Moderate alcohol consumption before bed

Pharmacologic:

› Anti-hypertensives taken at HS

› Nitroglycerin patch and nifedipine studied

with effect in pts with autonomic dysfunction


Any treatment for OH will likely worsen SH

Treating SH can worsen the symptoms of

OH, especially in the morning

› There is an increased risk of falls in patients

with nocturia if using pharmacologic

management


Not enough data on the prognosis of SH to

determine who should be treated

24 ambulatory BP monitoring a useful tool in

determining extent of SH and may help to

guide the decision to treat

Treatment should be initiated if a pt

experiences end-organ complications from

SH (i.e. hemorrhagic stroke)


Shibao, C et al (2012). Pharmacotherapy of autonomic

failure. Pharmacology & Therapeutics. 134 (3): 279-286

Ejaz, AA et al (2007). 24-Hour blood pressure monitoring in the

evaluation of supine hypertension and orthostatic

hypotension. The Journal of Clinical Hypertension. 9 (12): 952-

955.

Jordan, J & Biaggioni, I (2002). Diagnosis and treatment of

supine hypertension in autonomic failure patients with

orthostatic hypotension. The Journal of Clinical Hypertension.

4 (2): 139-145.

Gupta V et al (2007). Orthostatic hypotension in the elderly:

diagnosis and treatment. The American Journal of Medicine.

120:841-847.

Lanier, J et al (2011). Evaluation and management of

orthostatic hypotension. American Family Physician. 84 (5):

527-536.

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