The Info List - Orthostatic Hypotension

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Orthostatic hypotension, also known as postural hypotension,[1] occurs when a person's blood pressure falls when suddenly standing up from a lying or sitting position.[2] It is defined as a fall in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position. It occurs predominantly by delayed constriction of the lower body blood vessels, which is normally required to maintain an adequate blood pressure when changing position to standing. As a result, blood pools in the blood vessels of the legs for a longer period and less is returned to the heart, thereby leading to a reduced cardiac output. Mild orthostatic hypotension is common and can occur briefly in anyone, although it is prevalent in particular among the elderly and those with known low blood pressure. Severe drops in blood pressure can lead to fainting, with a possibility of injury. There are numerous possible causes for orthostatic hypotension, such as certain medications (e.g. alpha blockers), autonomic neuropathy, decreased blood volume, and age-related blood vessel stiffness. Apart from addressing the underlying cause, orthostatic hypotension may be treated with a recommendation to increase salt and water intake (to increase the blood volume), wearing compression stockings, and sometimes medication (fludrocortisone, midodrine or others).


1 Signs and symptoms 2 Causes

2.1 Hypovolemia 2.2 Diseases 2.3 Medication 2.4 Other factors

3 Diagnosis 4 Management

4.1 Non-pharmacological management 4.2 Pharmacological management

5 Prognosis 6 See also 7 References 8 External links

Signs and symptoms[edit] Orthostatic hypotension
Orthostatic hypotension
is characterised by symptoms that occur after standing (from lying or sitting), particularly when this is done rapidly. Many report lightheadedness (a feeling that one might be about to faint), sometimes severe. Generalized weakness or tiredness may also occur. Some also report difficulty concentrating, blurred vision, tremulousness, vertigo, anxiety, palpitations (awareness of the heartbeat), feeling sweaty or clammy, and sometimes nausea. A person may look pale.[3] Causes[edit] Orthostatic hypotension
Orthostatic hypotension
is caused primarily by gravity-induced blood pooling in the lower extremities, which in turn compromises venous return, resulting in decreased cardiac output and subsequent lowering of arterial pressure. For example, changing from a lying position to standing loses about 700 ml of blood from the thorax, with a decrease in systolic and diastolic blood pressures.[4] The overall effect is an insufficient blood perfusion in the upper part of the body.[citation needed] Still, the blood pressure does not normally fall very much, because it immediately triggers a vasoconstriction (baroreceptor reflex), pressing the blood up into the body again. (Often, this mechanism is exaggerated and is why diastolic blood pressure is a bit higher when a person is standing up, compared to a person in the horizontal position.) Therefore, a secondary factor that causes a greater than normal fall in blood pressure is often required. Such factors include low blood volume, diseases, and medications.[citation needed] Hypovolemia[edit] Orthostatic hypotension
Orthostatic hypotension
may be caused by low blood volume, bleeding, the excessive use of diuretics, vasodilators, or other types of drugs, dehydration, or prolonged bed rest(immobility); as well as occurring in people with anemia.[5] Diseases[edit] The disorder may be associated with Addison's disease, atherosclerosis (build-up of fatty deposits in the arteries), diabetes, pheochromocytoma, porphyria,[6] and certain neurological disorders, including multiple system atrophy and other forms of dysautonomia. It is also associated with Ehlers–Danlos syndrome
Ehlers–Danlos syndrome
and anorexia nervosa. It is also present in many patients with Parkinson's disease
Parkinson's disease
resulting from sympathetic denervation of the heart or as a side-effect of dopaminomimetic therapy. This rarely leads to fainting unless the person has developed true autonomic failure or has an unrelated heart problem.[citation needed] Another disease, dopamine beta hydroxylase deficiency, also thought to be underdiagnosed, causes loss of sympathetic noradrenergic function and is characterized by a low or extremely low levels of norepinephrine, but an excess of dopamine.[7] Quadriplegics and paraplegics also might experience these symptoms due to multiple systems' inability to maintain a normal blood pressure and blood flow to the upper part of the body.[citation needed] Medication[edit]


Orthostatic hypotension
Orthostatic hypotension
can be a side-effect of certain antidepressants, such as tricyclics[8] or monoamine oxidase inhibitors (MAOIs).[9] Marijuana and tetrahydrocannabinol can on occasion produce marked orthostatic hypotension.[10] Alcohol can also potentiate orthostatic hypotension to the point of syncope.[11] Orthostatic hypotension can also be a side effect of alpha-1 blockers (alpha1 adrenergic blocking agents). Alpha1 blockers inhibit vasoconstriction normally initiated by the baroreceptor reflex upon postural change and the subsequent drop in pressure.[12] Other factors[edit] Patients prone to orthostatic hypotension are the elderly, post partum mothers, and those having been on bedrest. People suffering from anorexia nervosa and bulimia nervosa often suffer from orthostatic hypotension as a common side-effect. Consuming alcohol may also lead to orthostatic hypotension due to its dehydrating effects.[citation needed] Diagnosis[edit] Orthostatic hypotension
Orthostatic hypotension
can be confirmed by measuring a person's blood pressure after lying flat for 5 minutes, then 1 minute after standing, and 3 minutes after standing.[13] Orthostatic hypotension
Orthostatic hypotension
is defined as a fall in systolic blood pressure of at least 20 mmHg and/or in the diastolic blood pressure of at least 10 mmHg between the supine reading and the upright reading. In addition, the heart rate should also be measured for both positions. A significant increase in heart rate from supine to standing may indicate a compensatory effort by the heart to maintain cardiac output or postural orthostatic tachycardia syndrome (POTS). A tilt table test may also be performed.[citation needed] Management[edit] Non-pharmacological management[edit] Apart from treating underlying reversible causes (e.g., stopping or reducing certain medications), there are a number of measures that can improve the symptoms of orthostatic hypotension and prevent episodes of syncope. Even small increases in the blood pressure may be sufficient to maintain blood flow to the brain on standing.[14] In people who do not have a diagnosis of high blood pressure, drinking 2–3 liters of fluid a day and taking 10 grams of salt can improve symptoms, by maximizing the amount of fluid in the bloodstream.[14] Another strategy is keeping the head of the bed slightly elevated. This reduces the return of fluid from the limbs to the kidneys at night, thereby reducing nighttime urine production and maintaining fluid in the circulation.[14] Various measures can be used to improve the return of blood to the heart: the wearing of compression stockings and exercises ("physical counterpressure manoeuvres" or PCMs) that can be undertaken just before standing up (e.g., leg crossing and squatting).[14] Pharmacological management[edit] The medication midodrine can benefit people with orthostatic hypotension,[14][15] The main side-effect is piloerection ("goose bumps").[15] Fludrocortisone
is also used, although based on more limited evidence.[14] A number of other measures have slight evidence to support their use indomethacin, fluoxetine, dopamine antagonists, metoclopramide, domperidone, monoamine oxidase inhibitors with tyramine (can produce severe hypertension), oxilofrine, potassium chloride, and yohimbine.[16] Prognosis[edit] Orthostatic hypotension
Orthostatic hypotension
may cause accidental falls.[17] It is also linked to an increased risk of cardiovascular disease, heart failure, and stroke.[18] There is also observational data suggesting that orthostatic hypotension in middle age increases the risk of eventual dementia and reduced cognitive function.[19] See also[edit]

Orthostatic intolerance Orthostatic hypertension Postural orthostatic tachycardia syndrome Vasovagal response


^ "Orthostatic hypotension" at Dorland's Medical Dictionary ^ "Orthostatic Hypotension Information Page National Institute of Neurological Disorders and Stroke". www.ninds.nih.gov. Retrieved 2017-03-26.  ^ Kasper DL, Fauci AS, Hauser SL, Longo DL, James JL, Loscalzo J (2015). Harrison's principles of internal medicine. 2 (19th ed.). New York: McGraw-Hill Medical Publishing Division. p. 2639. ISBN 978-0-07-180215-4.  ^ Idiopathic Orthostatic Hypotension and other Autonomic Failure Syndromes at eMedicine ^ "What Causes Hypotension? - NHLBI, NIH". www.nhlbi.nih.gov. Retrieved 27 March 2017.  ^ Sim, M; Hudon, R (1979). "Acute intermittent porphyria associated with postural hypotension". Canadian Medical Association Journal. 121 (7): 845–6. PMC 1704473 . PMID 497968.  ^ "Dopamine Beta-Hydroxylase Deficiency". GeneReviews — NCBI Bookshelf.  ^ Jiang, Wei; Davidson, Jonathan R.T (2005). "Antidepressant therapy in patients with ischemic heart disease". American Heart Journal. 150 (5): 871–81. doi:10.1016/j.ahj.2005.01.041. PMID 16290952.  ^ Delini-Stula, A; Baier, D; Kohnen, R; Laux, G; Philipp, M; Scholz, H.-J (2007). "Undesirable Blood Pressure Changes Under Naturalistic Treatment with Moclobemide, a Reversible MAO-A Inhibitor - Results of the Drug Utilization Observation Studies". Pharmacopsychiatry. 32 (2): 61–7. doi:10.1055/s-2007-979193. PMID 10333164.  ^ Jones, Reese T (2002). "Cardiovascular System Effects of Marijuana". The Journal of Clinical Pharmacology. 42 (11 Suppl): 58S–63S. doi:10.1002/j.1552-4604.2002.tb06004.x. PMID 12412837.  ^ Narkiewicz, K; Cooley, R. L; Somers, V. K (2000). "Alcohol potentiates orthostatic hypotension : Implications for alcohol-related syncope". Circulation. 101 (4): 398–402. PMID 10653831.  ^ Orthostatic Hypotension at Merck Manual of Diagnosis and Therapy Home Edition ^ "STEADI - Measuring Orthostatic Blood Pressure" (PDF). Centers for Disease Control and Prevention. Retrieved 20 December 2014.  ^ a b c d e f Moya, A; Sutton, R; Ammirati, F; Blanc, J.-J; Brignole, M; Dahm, J. B; Deharo, J.-C; Gajek, J; Gjesdal, K; Krahn, A; Massin, M; Pepi, M; Pezawas, T; Granell, R. R; Sarasin, F; Ungar, A; Van Dijk, J. G; Walma, E. P; Wieling, W; Abe, H; Benditt, D. G; Decker, W. W; Grubb, B. P; Kaufmann, H; Morillo, C; Olshansky, B; Parry, S. W; Sheldon, R; Shen, W. K; et al. (2009). "Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology
(ESC)". European Heart Journal. 30 (21): 2631–71. doi:10.1093/eurheartj/ehp298. PMC 3295536 . PMID 19713422.  ^ a b Izcovich, A; Gonzalez Malla, C; Manzotti, M; Catalano, H. N; Guyatt, G (2014). " Midodrine
for orthostatic hypotension and recurrent reflex syncope: A systematic review". Neurology. 83 (13): 1170–7. doi:10.1212/WNL.0000000000000815. PMID 25150287.  ^ Logan, Ian C; Witham, Miles D (2012). "Efficacy of treatments for orthostatic hypotension: A systematic review". Age and Ageing. 41 (5): 587–94. doi:10.1093/ageing/afs061. PMID 22591985.  ^ Romero-Ortuno, Roman; Cogan, Lisa; Foran, Tim; Kenny, Rose Anne; Fan, Chie Wei (2011). "Continuous Noninvasive Orthostatic Blood Pressure Measurements and Their Relationship with Orthostatic Intolerance, Falls, and Frailty in Older People". Journal of the American Geriatrics Society. 59 (4): 655–65. doi:10.1111/j.1532-5415.2011.03352.x. PMID 21438868.  ^ Ricci, Fabrizio; Fedorowski, Artur; Radico, Francesco; Romanello, Mattia; Tatasciore, Alfonso; Di Nicola, Marta; Zimarino, Marco; De Caterina, Raffaele (2015). "Cardiovascular morbidity and mortality related to orthostatic hypotension: A meta-analysis of prospective observational studies". European Heart Journal. 36 (25): 1609–17. doi:10.1093/eurheartj/ehv093. PMID 25852216.  ^ Rawlings, Andreea; et al. (March 2017). Orthostatic Hypotension is Associated With 20-year Cognitive Decline and Incident Dementia: the Atherosclerosis
Risk in Communities (ARIC) Study (PDF). Epidemiology and Prevention / Lifestyle and Cardiometabolic Health 2017 Scientific Sessions. Portland, Oregon. CS1 maint: Explicit use of et al. (link)

External links[edit]


V · T · D

ICD-10: I95.1 ICD-9-CM: 458.0 MeSH: D007024 DiseasesDB: 10470

Orthostatic hypotension
Orthostatic hypotension
at Curlie (based on DMOZ)

v t e

Diseases of the autonomic nervous system (G90, 337)


I II III/Familial dysautonomia IV/Congenital insensitivity to pain with anhidrosis V

Orthostatic intolerance

Postural orthostatic tachycardia syndrome Orthostatic hypotension


Horner's syndrome Multiple system atrophy Pure autonomic failure Autonomic dysreflexia Dysautonomia Autonomic neuropathy

v t e

Cardiovascular disease
Cardiovascular disease
(vessels) (I70–I99, 440–456)

Arteries, arterioles and capillaries




Buerger's disease

Peripheral artery disease



Foam cell Fatty streak Atheroma Intermittent claudication Critical limb ischemia

Monckeberg's arteriosclerosis Arteriolosclerosis

Hyaline Hyperplastic Cholesterol LDL Oxycholesterol Trans fat


Carotid artery stenosis Renal artery stenosis


Aortoiliac occlusive disease Degos disease Erythromelalgia Fibromuscular dysplasia Raynaud's phenomenon

/ dissection / pseudoaneurysm

torso: Aortic aneurysm

Abdominal aortic aneurysm Thoracic aortic aneurysm Aneurysm
of sinus of Valsalva

Aortic dissection Coronary artery aneurysm head / neck

Intracranial aneurysm Intracranial berry aneurysm Carotid artery dissection Vertebral artery dissection Familial aortic dissection

Vascular malformation

Arteriovenous fistula Arteriovenous malformation Telangiectasia

Hereditary hemorrhagic telangiectasia

Vascular nevus

Cherry hemangioma Halo nevus Spider angioma




Venous thrombosis
Venous thrombosis
/ Thrombophlebitis

primarily lower limb

Deep vein thrombosis


Hepatic veno-occlusive disease Budd–Chiari syndrome May–Thurner syndrome Portal
vein thrombosis Renal vein thrombosis

upper limb / torso

Mondor's disease Paget–Schroetter disease


Cerebral venous sinus thrombosis

Post-thrombotic syndrome

Varicose veins

Gastric varices Portacaval anastomosis

Caput medusae Esophageal varices Hemorrhoid



Chronic venous insufficiency Chronic cerebrospinal venous insufficiency Superior vena cava syndrome Inferior vena cava syndrome Venous ulcer

Arteries or veins


Macroangiopathy Microangiopathy


Pulmonary embolism Cholesterol
embolism Paradoxical embolism

Thrombosis Vasculitis

Blood pressure


Hypertensive heart disease Hypertensive emergency Hypertensive nephropathy Essential hypertension Secondary hypertension

Renovascular hypertension

Benign hypertension Pulmonary hypertension Systolic hypertension White coat hypertension