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Orthostatic Hypotension
- 1. ORTHOSTATIC HYPOTENSION DrAMIT KUMAR MALLIK DEPT. OF PHYSICAL MEDICINE AND REHABILITATION RIMS,IMPHAL
- 2. Definition BLOOD PRESSURE The pressure exerted by flowing column of blood on arterial wall. Normal BP- Systolic 100-140 mm Hg Diastolic 60-90 mm Hg
- 3. Orthostatic hypotension •Decrease in systolic BP≥20 mm Hg or decrease in diastolic BP≥10 mm Hg within 3 minutes of standing when compared with BP from sitting or supine position or • Similar drop in BP within 3 minutes in a head up position on tilt table test at angle ≥60°
- 4. Normal mechanism ofBP regulation There are two basic mechanisms for regulating blood pressure: (1) short-term mechanisms (2) long-term mechanisms Blood Pressure = cardiac output x peripheral resistance
- 5. Location of Baroreceptorand Chemoreceptor
- 6. Control of Bloodpressure I. Nervous system II. Chemoreceptor
- 7. I. Nervous System • Control BP by changing blood distribution in the body and by changing blood vessel diameter. • Sympathetic & Parasympathetic activity • The vasomotor center – medulla It sends efferent motor fibers that innervate smooth muscle of blood vessels
- 8. Regulation of RisingBlood Pressure
- 9. Baroreceptors • Thebest known of nervous mechanisms for arterial pressure control(baroreceptor reflex) • Baroreceptor are stretch receptors found in the carotid sinus ,aortic sinus • Respond more to a rapidly changing pressure than stationary
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- 11. Effect of Baroreceptors EFFECT VASODILATATION OF THE VEINS AND ARTERIOLES DECREASED HEART RATE AND STRENGTH OF HEART CONTRACTION Therefore, excitation of baroreceptors by high pressure in the arteries reflexly causes arterial pressure to decrease (as decrease in PR and CO)
- 12. Increased Parasympathetic Activity • Reduction of heart rate • Lower cardiac output • Lower blood pressure
- 13. Regulation of FallingBlood Pressure Baroreceptors inhibited Decreased impulses to the brain Decreased parasympathetic activity, increased sympathetic activity Effects Heart increased heart rate and increased contractility Vessels increased vasoconstriction Adrenal gland release of epinephrine and norepinephrine which enhance heart rate Contractility and vasoconstriction Increased blood pressure
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- 16. Chemoreceptor • Chemosensitivecells that respond to changes in pCO2 and pO2 and pH levels (Hydrogen ion). pO2 and pH pCO2 Stimulation of vasomotor center CO HR vasoconstriction BP (speeding return of blood to the heart and lungs)
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- 18. • Any interruptionin the body's natural process of counteracting low blood pressure
- 19. Causes of PosturalHypotension Neurogenic causes Primary causes- Autonomic failure due to idiopathic central and peripheral neurodegenerative diseases—the “synucleinopathies” • Parkinson’s disease • Lewy body dementia • Pure autonomic failure • Multiple system atrophy (Shy-Drager syndrome)
- 20. Secondary causes 1.Spinalcord injury 2.Secondary autonomic failure • Diabetes • Hereditary amyloidosis (familial amyloid polyneuropathy) • Primary amyloidosis (AL amyloidosis; immunoglobulin light chain associated)
- 21. • Idiopathic immune-mediatedautonomic neuropathy • Autoimmune autonomic ganglionopathy • HIV neuropathy
- 22. Non-neurogenic Causes ofOrthostatic Hypotension • Age related Cardiac pump failure • Myocardial infarction • Myocarditis • Constrictive pericarditis • Aortic stenosis • Tachy-arrhythmias • Brady-arrhythmias
- 23. Reduced intravascular volume • Dehydration • Diarrhea, emesis • Hemorrhage • Burns
- 24. Metabolic • Adrenocorticalinsufficiency • Hypo-aldosteronism • Pheo-chromocytoma • Severe potassium depletion
- 25. Venous pooling •Postprandial dilation of splanchnic vessel beds • Vigorous exercise with dilation of skeletal vessel beds • Heat: hot environment, hot showers and baths, fever • Prolonged recumbency or standing
- 26. Medications • Antihypertensives • Diuretics • Vasodilators: nitrates, hydralazine • Alpha- and beta-blocking agents • CNS sedatives: barbiturates,opiates • Tricyclic antidepressants • Phenothiazines
- 27. Symptoms Characteristic symptomsare • Light-headedness • Dizziness • Presyncope (near-faintness) However, symptoms may be absent or nonspecific like • Generalized weakness • Fatigue • Cognitive slowing • Headache.
- 28. • Visual blurring • Neck pain—typically in -suboccipital -posterior cervical -shoulder region ( “coat-hanger headache”)
- 29. • Patients mayreport orthostatic dyspnea • Symptoms may be exacerbated by exertion, prolonged standing, increased ambient temperature, or meals • Syncope is usually preceded by warning symptoms, but may occur suddenly, suggesting the possibility of a seizure or cardiac cause
- 30. Percentage wise symptoms • Lightheadedness (dizziness) 88% • Weakness or tiredness 72% • Cognitive difficulty (thinking/concentrating) 47% • Blurred vision 47% • Tremulousness 38% • Vertigo 37% • Pallor 31% • Anxiety 29% • Palpitations 26% • Clammy feeling 19% • Nausea 18%
- 31. Diagnosis • Bytaking BP in supine and standing • By comparing both BP
- 32. Management Non pharmacological • Patient education: mechanisms and stressors of OH • Compression garments
- 33. • The headof the bed of a patient with orthostatic hypotension should be elevated by 10 to 20 degrees or 4 inches (10 cm)
- 34. • Move legswhile standing • Get up slowly • Avoid bending at waist • FES • Exercise-Calf muscle exercise, when getting out of bed, sit on edge of bed for a minute before standing
- 35. • High-salt diet(1g/d) QID • High-fluid intake (2 l/d) • Learn physical counter-maneuvers • Correct anemia
- 36. Medicines(pharmacological) • Fludrocortisone • L-dopa-to treat hypotension a/w Parkinson ds. • Midodrine or Ephedrine • Erythropoitin • Pyridostigmine
- 38.