My Patient Cannot Stand Up: What to do about Orthostatic Hypotension

摘要

Orthostatic hypotension is a mutifactorial geriatric syndrome. Patients have a chronic debilitating symptom that occurs while standing from a supine position. Common postural symptoms include lightheadness, dizziness, presyncope and syncope. Other non-specific symptoms such as weakness and fatigue may also present. Standing from a supine position will lead to pooling of approximately 700 ml of blood to the dependent areas of the abdomen and lower extremities. Healthy individuals are able to maintain optimal blood pressure and perfusion to the brain due to activation of baroreflex and sympathetic nervous stimulation. With failure of neural and circulatory mechanism, patients with autonomic failure are unable to compensate, leading drop in blood pressure. Good history and physical examination (including postural vital signs) are the keys to the diagnosis. Autonomic function testing that involves the Valsalva maneuver to identify neurogenic autonomic failure can be done in various autonomic clinics. Initial treatment is focused on addressing reversible causes such as volume depletion and medication use. Non-pharmacologic interventions and pharmacologic measures that aid volume expansion and increase vascular resistance can improve orthostatic symptoms when initiated.