What Are The First Symptoms Of Orthostatic Hypotension & How Do You Test For It?

Orthostatic hypotension corresponds to a decrease in blood pressure when moving from the lying or sitting position to the standing position. It manifests as dizziness, visual disturbances, a feeling of weakness and sometimes even discomforts accompanied by a fall with the loss of consciousness.(1)

What Are The First Symptoms Of Orthostatic Hypotension?

During the episode of orthostatic hypotension, the patient may present with a brief loss of consciousness or discomfort with dizziness and visual disturbances. In brief, orthostatic hypotension is manifested by the following symptoms, occurring in the immediate or rapid aftermath of standing:

In the case of Shy-Drager syndrome, orthostatic hypotension is associated with:

  • Urinary incontinence
  • Dizziness with loss of consciousness
  • Impotence
  • A decreased sweating.(3)

How Do You Test For Orthostatic Hypotension?

The reality of orthostatic hypotension should be confirmed by repeated measurements of blood pressure when lying down and when standing.

The diagnosis of orthostatic hypotension is made by measuring blood pressure and pulse, first lying down and at rest for more than five minutes, or even more ideally, then as soon as the person stands up, taking board and pulse are 1, 3, 5 and 10 minutes after switching from the lying position to the standing position.

In the case of orthostatic hypotension, a reduction of more than 30 millimetres of mercury (reference unit) in systolic pressure is retained at one of these intakes, or a decrease of more than 20 millimetres of mercury for diastolic blood pressure is observed. 

The variation in the pulse will point towards a cause. Even if the drop in pressure is generally immediate, measurements up to 10 minutes are necessary to see the adaptation of the patient to this drop in blood pressure. Also, in patients with venous insufficiency or varicose veins, orthostatic hypotension may appear delayed.

A correctable cause must be sought. In the case of Shy-Drager syndrome, the doctor may find a pupillary areflexia: the pupil does not contract following a light stimulus.(3)

Additional Examinations And Analyzes

They are only useful for investigating the cause of orthostatic hypotension and are guided by the data of the clinical examination of the consultation.(4)

Causes Of Orthostatic Hypotension

Different problems may be involved: a decrease in the volume of blood in the vessels following an intervention, hemorrhage or dehydration, insufficient circulation of the veins in the legs, certain drugs or damage to the nervous system.

Orthostatic hypotension can be secondary: 

  • When taking certain drugs: neuroleptics, tricyclic antidepressants, antihypertensives (calcium channel blockers, ACE inhibitors, diuretics), phenothiazines;
  • A decrease in the volume of blood circulating in the vessels (hemorrhage or dehydration)
  • A reduction in blood potassium level
  • Endocrine disease: Addison’s disease, hypothyroidism, pheochromocytoma (tumor of the adrenal gland)
  • At prolonged bed rest responsible for an episode of orthostatic hypotension during the first lift
  • In the surgical section of certain nerves responsible for controlling blood pressure
  • To diseases affecting the nervous system (tabes dorsal, syringomyelia, diabetes, Shy-Drager syndrome)

In some cases, orthostatic hypotension remains without an identified cause.(2)

Treatment For Orthostatic Hypotension

The treatment of orthostatic hypotension is based on prevention rules. If they are insufficient, medicines like heptaminol or midodrine can be used. Treatment of orthostatic hypotension is usually only satisfactory in the more moderate forms.  It also aims to decrease symptoms, not to reach target blood pressure

It includes drug therapy and non-drug therapy. 

Drug Therapy: In the case of taking drugs known to be responsible for orthostatic hypotension, a change of treatment may be considered by the doctor in the event of ill-tolerated orthostatic hypotension.

In the absence of contraindications, drug treatment is indicated only in forms of neurogenic origin:  treatment with midodrine which has this indication is prescribed, oacr with fludrocortisone.

Other drugs have been successfully used to treat orthostatic hypotension: the cholinesterase inhibitor pyridostigmine appears to preferentially raise blood pressure while standing.

Non-Drug Therapy: Symptoms can be improved by:

  • Hygienic-dietary advice: get up slowly, avoid lying down for too long, avoid anxiolytics and alcohol
  • Wearing varicose stockings up to the waist
  • A diet rich in salt
  • The elevation of the head of the bed.(5)(6)

Prevention Of Orthostatic Hypotension

The prevention of orthostatic hypotension is often done on the advice of a healthy lifestyle and good hydration, explaining the need to get up gradually and wait before embarking on walking.

References:

  1. Suraj R, Hodge S, Spence EE, et al. Cerebrovascular Consequences of Chronic Orthostatic Hypotension. The FASEB Journal. 2019;33(1_supplement):533.516-533.516.
  2. Ricci F, Manzoli L, Sutton R, et al. Hospital admissions for orthostatic hypotension and syncope in later life: insights from the Malmö Preventive Project. Journal of hypertension. 2017;35(4):776-783.
  3. Palma JA, Kaufmann H. Epidemiology, diagnosis, and management of neurogenic orthostatic hypotension. Movement disorders clinical practice. 2017;4(3):298-308.
  4. McGrath R, McGrath R, Snih S, Markides K, Hall O, Peterson M. The Burden of Health Conditions for Aging Adults in the United States: Disability-Adjusted Life Years. Journal of the American Medical Directors Association. 2019;20(3):B33.
  5. Liguori I, Russo G, Coscia V, et al. Orthostatic hypotension in the elderly: a marker of clinical frailty? Journal of the American Medical Directors Association. 2018;19(9):779-785.
  6. Hale GM, Valdes J, Brenner M. The treatment of primary orthostatic hypotension. Annals of Pharmacotherapy. 2017;51(5):417-428.

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