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Gen Med Unit 7: Cardio > Orthostatic Hypotension > Flashcards

Orthostatic Hypotension Flashcards

1
Q

Define orthostatic hypotension

A
  1. Excessive fall in BP when upright position assumed
  2. Abnormal BP regulation
    A. Due to another disorder
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2
Q

How much does the systolic bp drop in orthostatic hypotension?

A

> 20 mmHg

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3
Q

How much does the diastolic bp drop in orthostatic hypotension?

A

10 mm/Hg

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4
Q

What are the sxs of orthostatic hypotension?

A
  1. Faintness
  2. Lightheadedness
  3. Dizziness
  4. Blurred vision
    A. Can cause falls, syncope or generalized seizures
  5. Occurs within sec/min of standing
  6. Resolves with lying down
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5
Q

What normally happens to blood distribution, venous return, CO, and BP when standing?

A
  1. Normally standing pools ½ - 1L blood in leg/trunk veins
    A. Leads to ↓ venous return
    B. ↓ CO and BP
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6
Q

What is the physiologic response to standing?

A
  1. Baroreceptors (aortic arch & carotid bulbs) activate autonomic reflexes to return BP to normal
  2. Sympathetic system ↑ HR, contractility and vasomotor tone in veins
  3. Parasympathetic inhibition also ↑ HR
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7
Q

What is the physiologic response to prolonged standing?

A
  1. Activates renin-angiotensin-aldosterone system and ADH secretion causing Na and H2O retention
    A. ↑ blood volume, CO
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8
Q

What is the pathophys of orthostatic hypotension?

A
  1. Physiologic mechanisms may be inadequate to restore low BP after standing if:
    A. Autonomic response impaired by disorders or drugs
    B. Myocontractility depressed
    C. Vascular responsiveness depressed
    D. Hypovolemia
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9
Q

What is the etiology of acute orthostatic hypotension?

A 
1. Hypovolemia (most common)
A. Fluids, blood loss
2. Drugs
3. Prolonged bed rest
4. Adrenal insufficiency
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10
Q

What is the etiology of chronic orthostatic hypotension?

A
  1. Age related
  2. Drugs
  3. Autonomic dysfunction
    A. Parkinson’s Dz
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11
Q

What questions need to be asked when investigating the history of a pt with orthostatic hypotension?

A
  1. Duration and severity of sxs
  2. Association with syncope or falls
  3. Known triggers
    A. Drugs
    -Alpha blockers (peripheral)
    -Diuretics
    -Nitrates
    -CCB
    B. Prolonged bed rest
    C. Fluid loss
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12
Q

If orthostatic hypotension is asst with aphasia, dysarthria, facial droop and hemiparesis, what may be the underlying cause?

A

Stroke

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13
Q

If orthostatic hypotension is asst with cardiac murmur or gallop, what may be the underlying cause?

A

CHF, MI

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14
Q

If orthostatic hypotension is asst with cogwheel rigidity, festinating gait, lack of truncal rotation, and masked facies, what may be the underlying cause?

A

Parkinson’s disease

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15
Q

If orthostatic hypotension is asst with confusion, dry mouth, dry tongue, longitudinal tongue furrows, speech difficulty, sunken eyes, and upper bdy weakness, what may be the underlying cause?

A

Dehydration (in older pts)

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16
Q

If orthostatic hypotension is asst with decreased libido, impotence in men, urinary retention and incontinence in women, what may be the underlying cause?

A

Autonomic failure

17
Q

If orthostatic hypotension is asst with dependent lower extremity edema and stasis dermatitis what may be the underlying cause?

A

Right sided congestive heart failure, venous insufficency

18
Q

How is bp measured if orthostatic hypotension is suspected?

A
  1. Check BP & HR after 5 min supine 2. BP 1 min sitting
  2. BP 1 min standing OR (BP & HR 1-3 min standing)
19
Q

What does hypotension without increased hr indicate?

A

Autonomic impairment

20
Q

What does hypotension with marked increased hr indicate?

A

HR (>100 bpm or ↑ 30 bpm)

Hypovolemia

21
Q

What findings may be present on a skin exam in a pt with orthostatic hypotension?

A
  1. Skin/mucus membranes
    A. Dehydration
    B. Pigmentation changes
    -Hyperpigmentation – Addison disease
22
Q

What findings may be present on a rectal exam in a pt with orthostatic hypotension?

A

Positive heme in stool

23
Q

What findings may be present on a neuro exam in a pt with orthostatic hypotension?

A
  1. GU and rectal reflexes evaluate autonomic function
  2. Abnormal strength, sensation and DTR’s
    A. Peripheral neuropathy
24
Q

What are red flags on the PE?

A
  1. Blood/heme (+) stool

2. Abnormal neurologic exam

25
Q

What dx studies should be performed on a pt with orthostatic hypotension?

A
  1. EKG
  2. BUN, Cr, lytes, glucose
  3. CBC
  4. Bedside cardiac monitoring
    A. R/O arrhythmia
  5. Tilt table testing
26
Q

Why is tilt table testing indicated?

A
  1. High probability of orthostatic hypotension despite an initial negative evaluation (e.g., Parkinson disease)
  2. Patients with significant motor impairment that precludes them from having standing vital signs obtained
27
Q

What are normal tilt table results?

A
  1. HR increases by 10-15 bpm

2. DBP increases by 10 mmHG or more

28
Q

What are tilt table results that indicate dysautonomia?

A
  1. Immediate and continuing drop in BP

2. No compensatory increase in HR

29
Q

What are tilt table results that indicate neurocardiogenic syncope?

A
  1. Symptomatic, sudden drop in BP
  2. Simultaneous bradycardia
  3. Occurs after 10 mins or more of testing
30
Q

What are the non-medical treatment options for orthostatic hypotension?

A
  1. Reduce or D/C offending medication
  2. Change positions slowly
  3. Adequate hydration
  4. Limit or avoid alcohol
  5. Regular exercise
    A. Promotes vascular tone → ↓ venous pooling
  6. Elderly - avoid prolonged standing
  7. Support pantyhose
    A. ↑ venous return, CO, & BP after standing
  8. Increase Na intake
    A. If no HTN or CHF
31
Q

What are the medical treatment options for orthostatic hypotension?

A
  1. Fludrocortisone (Florinef) 0.1 mg
  2. Midodrine (Orvaten, ProAmatine)
  3. Pyridostigmine(NAPPS, Mestinon)
32
Q

What is the class and moa of Fludrocortisone (Florinef)? How is it dosed?

A
  1. Mineralcorticoid
  2. Causes Na retention
  3. 0.1 mg-0.2 mg PO qd
    A. Titrate weekly until trace of pedal edema
    B. Max 1 mg/day
33
Q

What is the class and moa of Midodrine (Orvaten, ProAmatine)? How is it dosed?

A
  1. Inotrope/Pressor
  2. Stimulates alpha-1 adrenergic receptors
  3. Causes arterial and venous constriction
  4. 2.5 mg PO tid
    A. Titrate weekly
    B. Max 10 mg PO tid
34
Q

What is the class and moa of Pyridostigmine(NAPPS, Mestinon)? How is it dosed? What else is it used for?

A 
1. Used for neurogenic orthostasis
A. Myasthenia gravis
2. Cholinesterase inhibitor
3. Affects autonomic response
4. Increases total peripheral resistance
5. 30 mg PO bid-tid
A. Titrate weekly
B. Max 60 mg PO tid

Gen Med Unit 7: Cardio (13 decks)

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