It’s a common thing for physicians to encounter patients with orthostatic hypotension (OH), a condition characterized by the failure to maintain blood pressure while standing. More than one-fifth of patients over 60 have OH, and the stakes are high for them, as it is associated with increased falls, fractures and even death
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But OH is also difficult to diagnose because of its variable presentations and nonspecific symptoms, such as lightheadedness, weakness, fatigue, visual blurring, and neck and shoulder pain. In addition, some patients with OH are altogether asymptomatic
A review published in JAMA Internal Medicine summarizes management of orthostatic hypotension. It starts off by highlighting the most common conditions that can cause or exacerbate OH to help physicians spot patients at risk
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Primary care doctors play crucial role
“Because patients with OH often first present in primary care settings,” the review notes, “internists must be prepared to recognize potential OH and assess its character, effects on patient health and underlying cause.”
The review provides a discussion of the pathophysiology, assessment and diagnosis of OH. It also gives a breakout of pharmacological and nonpharmacological treatment options
“While certain medications and diagnostic tests typically fall under the purview of autonomic specialists, a large portion of the recommended evaluation and initial approach to treatment can be undertaken in primary care,” the authors wrote
8 conditions that drive OH
There are two primary categories of conditions that contribute to orthostatic hypotension, the review notes
The first category is related to neurogenic OH, from neurodegenerative diseases to systemic causes. These are:
Primary autonomic failure, including pure autonomic failure, Parkinson’s disease, multiple system atrophy and dementia with Lewy bodies
Peripheral autonomic neuropathy, such as diabetes, amyloidosis, B12 deficiency, and toxic and metabolic neuropathies
Autoimmune autonomic disorders, including autoimmune autonomic ganglionopathy, paraneoplastic syndrome and Sjogren syndrome
Spinal cord disorders, such as tetraplegia
The second category is related to non-neurogenic OH, specifically:
Medications, such as vasodilators, β-blockers, central α-2 agonists and diuretics
Hypovolemia, including from dehydration, hemorrhage/anemia and diarrhea/vomiting
Excessive venous pooling, such as venous stasis of lower limbs, deconditioning, hot environment and prolonged standing
Cardiac disorders, including arrhythmias, heart failure with reduced ejection fraction, aortic stenosis and myocarditis
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How to assess, diagnose and treat
“All patients presenting with orthostatic symptoms (i.e., symptoms that occur only when upright and improve when seated or lying down) should be assessed for OH,” the review advises
Initial diagnostic testing is typically performed with an active stand test, although the sit-to-stand test and the head-up tilt test are alternatives.
The review notes the importance of also assessing for supine hypertension and postprandial hypotension, as these conditions are frequently associated with neurogenic OH, and recommends nonpharmacological treatments as first line in all cases
“Individualized treatment, regular monitoring and patient education are essential to improve symptoms, prevent falls and enhance quality of life,” it says. “Despite limited long-term evidence for most therapies, a patient-centered, stepwise approach remains the cornerstone of care.”
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