a case to discuss the DD of hypotensive patient

1. A case of hypotension
Haytham Soliman Ghareeb
Lecturer of cardiovascular medicine
Fayoum university

2. •25 year old female
•Not diabetic or hypertensive
•Average built BMI 23
•On continuous diet
•Came complaining of low blood pressure

3. •Condition started one year ago soon after she started her
diet
•Dizziness, palpitation and fatigue specially when she
wakes up
•The condition partially improve during the day
•It also improves when she lies flat
•She sought medical advice in a primary health care center

4. Primary health care center
• Her blood pressure was 90/50 mmHg in sitting position and
one minute after standing
• Her ECG was normal
• Her physical examination was normal
• Ordered echocardiogram was normal
• Her CBC was within normal range
• She was given oral Etilefrine-HCL 5mg tab BID

5. •Patient partially improved but she stopped the
treatment due to headache
•Symptoms regain soon after
•The condition was exaggerated and she needed IV
fluid for this hypotension once at a local hospital
•Then she came to our hospital seeking medial advice
What should we do?

6. Overview about hypotension

7. Definition
• Its is decrease in blood pressure that cause hypo perfusion of vital organs
specially the brain and heart
• Its not always related to a number so (90/60 mmHg) is not hypotension in
asymptomatic individual
• Usually a blood pressure below 80/50 mmHg cause hypotension
• A drop in systolic blood pressure of 20mmHg can cause hypotension
symptoms
• Severe hypotension can cause serious hypo-perfusion and shock

8. Mechanism hypotension
• decrease in cardiac output
• dilation of blood vessels
• decrease in blood volume
• Inhibition of brain centers that control blood pressure
• Impairment of the autonomic nervous system

9. Causes of hypotension

10. • Dehydration:
– Even minor dehydration can cause hypotension
– This effect is exaggerated in elderly people
• Blood loss:
– bleeding cause hypotension via volume depletion
– major bleeding cause sever hypotension and shock
• Cardiac disease:
– obstructive valvular lesions – myocardial infacrtion
– advanced heart failure – bradychardia
– myocarditis – cardiotoxic drugs

11. • Severe allergic reactions:
Reaction cause capillary vasodilation and blood pressure to drop
• Pancreatitis:
Fluids enters the inflamed tissues around the pancreas concentrating
the blood and reducing its volume
• Severe infection:
Any infections that enter the bloodstream can cause potentially fatal
drops in blood pressure
• Endocrinal disorders:
– hyper and hypo thyroidism – Diabetes
– Postgastrectomy – primary hypoaldosteronism
– pheochromocytoma

12. • Pregnancy:
– Hypotension is due to blood pulled into fetal circulation
– This condition recovers after delivery
• Medications:
– Diuretics, beta-blockers, alpha-blockers, calcium channel blockers
– Certain antidepressants (e.g. tricyclic )
– Drugs for Parkinson disease (carbidopa and levodopa)
– PDE5 inhibitor (Sildenafil) specially when combined with
nitroglycerin

13. Classification
• Postural or orthostatic hypotension (OH)
• Postprandial hypotension
• Neurally mediated hypotension
• Multiple system atrophy with orthostatic hypotension

14. Postural or orthostatic hypotension (OH)
• Decrease in systolic BP≥20 mm Hg or decrease in diastolic BP≥10 mm
Hg within 3 minutes of standing or Similar drop in BP within 3
minutes in a head up position on tilt table test at angle ≥60°
• strongly age-dependent, with prevalence ranging from 5% to 11% in
middle age to 30% or higher in the elderly
• Its due to failure of neuro and chemoreceptor mechanisms that
counteract decrease of blood volume during standing

15. Sequence
Rapid decrease in venous return to heart
Reduce ventricular filling
↓CO ↓BP
Provoke compensatory mechanisms
↓Parasympathetic ↑sympathetic
↑Peripheral resistance
↑venous return
Maintain BP with
•Small fall in SBP
(5-10mmHg)
•↑Diastolic Bp (5-10mmHg)
•↑Pulse rate 10-25 beat/min
Absent

16. • Postprandial hypotension:
– Occurs when blood pressure drops suddenly after eating
– due to pooling of blood in the intestine for digestion
– More common than postural hypotension
– Occurs mainly in the elderly
– Risk factors includes Parkinson disease, autonomic neuropathy

17. • Neurally mediated hypotension:
Occurs when blood pressure drops after standing for a long period of
time
• Multiple system atrophy with orthostatic hypotension:
– Also known as Shy-Drager syndrome
– Progressive damage to the autonomic nervous system
– It causes hypotension when standing and hypertension when lying
down.

18. Symptoms and signs
• Orthostatic Hypotension and Neurally Mediated Hypotension :
- Dizziness or light-headedness - Blurred vision
- Confusion - Weakness
- Fatigue - Nausea
• Orthostatic hypotension happen within a few seconds or minutes of
standing up and disappear with sitting or lying down
• NMH occur after standing for a long time or in response to a stressful
situation. The drop in blood pressure doesn't last long and often
disappear after sitting down.

19. Diagnostic tools other than blood pressure
measurement
• Laboratory work up:
CBC, blood electrolyte measurement, thyroid profile, cortisol levels,
blood and urine cultures if infection is suspected
• Radiologic studies:
ECG, echocardiogram, Holter monitor, lower limbs vemous duplex , CT
scan of the chest and abdomen and tilt-table tests

20. Treatment
• Mainly treatment of the cause ( endocrine disorders, heart failure,
medication side effects)
• Mild dehydration is treated with oral fluids and electrolytes
• Moderate-to-severe dehydration is usually treated in the hospital or
emergency room with IV fluids and electrolytes

21. Drug therapy
• Fludrocortisone
– very potent mineralocorticoid that Increase reabsorption of sodium
from distal renal tubules
– Recommended as first-line drug therapy in dehydration
– Given as 0.1 mg/day , increased by 0.1 mg per week; the maximum daily
dose is 1 mg/day .

22. • Midodrine:
– Alpha agonist that increases arteriolar and venous tone
– Rise standing, sitting, and supine systolic and diastolic blood pressure in
patients with orthostatic hypotension
– Dose is 10 mg three times per day during daytime (maximum dose is 40
mg/day)
– In the prevention of hemodialysis-induced hypotension (unlabeled use),
2.5 to 10 mg is given 15 to 30 minutes prior to a dialysis session
– The major side effect of this drug is supine hypertension

23. • Norepinephrine:
– A vasoactive agent that stimulates beta and alpha-adrenergic receptors
– It increased contractility and heart rate and thereby systemic blood pressure
– IV infusion in shock patients with an initial dose of 8 to 12 mcg/min
• Octreotide:
– A somatostatin analogue that inhibits release of gastrointestinal peptides, some
of which may cause vasodilation
– Subcutaneous doses given 30 minutes before a meal may be used to reduce
postprandial orthostatic hypotension
– Octreotide does not increase supine hypotension

24. Prevention
• Water Intake:
– Combat dehydration and increases blood volume
– Dehydrating drinks like alcohol and coffee should be avoided
– Triggers such as a high temperature environment must be avoided
• Compression stockings:
– They reduce pooling of blood in the legs and can prevent
hypotension
• Body positions:
– Patients should sit up and breathe deeply as they get out of bed in
the morning or when standing up from a sitting position
– Dorsiflexing their feet first and even crossing the legs while upright
can be helpful.

25. Back to our patient
• We took a carful history and we discovered that:
– She do not drink more than 1 liter of fluid/day
– She drinks a lot of coffee and tea
– In her diet she is taking a tricyclic antidepressant to help her reduce weight
– symptoms occur more when changing position form siting to prone

26. Examination and laboratory tests
• She had a baseline BP of 90/56 mm Hg in sitting position
• She has a marked drop of blood pressure after 3 min of standing
reduced to 70/50 with beginning of symptoms
• She had normal thyroid functions, cortisol level, kidney functions and
electrolytes

27. Treatment
• She was advised to:
– Drink at least 3 liters of fluid/day
– To stop coffee
– To stop antidepressant
• At follow up:
– Symptoms improved markedly but still present only in sudden rise
from sitting
– She refused to take any other medications
– She was advised to wear an elastic stoking with disappearance of
the symptoms

28. Take home message
• Hypotension is an important symptom with many causes
• It is not related to a fixed BP level
• BP must be measured both sitting and standing in all cases
• Proper history about patient hydration and drugs is a must
• Further investigations are guided by clinical presentation
• Prevention comes first
• Don’t begin drug therapy before knowing the cause of hypotention

29. Thank you