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How to diagnose orthostatic hypotension

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  • PMID: 25995335
  • DOI: 10.1093/bmb/ldv025
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Affiliation

  • PMID: 25995335
  • DOI: 10.1093/bmb/ldv025

Abstract

Background: Orthostatic hypotension (OH) is very common, particularly in older populations. Diagnostic criteria exist but appear to be arbitrary rather than evidence based. This review will visit the evidence for diagnostic strategies for OH.

Data sources: Medline (OvidSP), EMBASE (OvidSP), ISI Web of Science, the Health Technology Assessments Database and the Cochrane Library.

Areas of agreement: A 5-min rest is required before measuring baseline. An active stand with continuous blood pressure (BP) monitoring is preferable to a tilt test to identify initial OH in particular. At least 2 min in the upright position is required. A systolic drop of 20 or a diastolic drop of 10 is supported by the evidence. Reproducibility when testing for OH is poor.

Areas of controversy: Is the active stand preferable to the tilt test to diagnose classical OH? Although continuous BP monitoring increases diagnostic rates, does it improve clinical outcomes? Should symptoms be used to inform diagnosis?

Areas timely for research: Establishing the long-term clinical outcomes for transient drops in BP detected on continuous, non-invasive monitoring. Evaluating the different patterns of BP drop to aid diagnosis and direct treatment.

Keywords: diagnosis; orthostatic hypotension; postural hypotension.

What you need to know

Postural hypotension is a drop in blood pressure (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic) that occurs within 3 minutes of standing

Test for it in people who have symptoms of lightheadedness or dizziness on changing from lying or sitting to standing posture or those with an unexplained fall

Age over 60 years, diabetes, Parkinson’s disease, and certain medications increase the risk

The aim of treatment is to reduce symptoms (including risk of injury) and improve quality of life, rather than trying to reduce the postural drop in blood pressure

Evidence for both non-pharmacological and pharmacological interventions is poor, making it important to identify why a patient has postural hypotension and to address the underlying condition

Postural hypotension, also called orthostatic hypotension, is an abnormal drop in blood pressure on standing. It impairs quality of life and increases risk of falls, cardiovascular disease, depression, dementia, and death. 1 2 3 4 Early detection in patients with symptoms or certain risk factors may prevent some of these complications. Current guidelines for detecting and managing postural hypotension are varied and based on limited evidence. Primary care providers play an important role in screening and detection of postural hypotension and in helping patients make shared treatment decisions to improve symptoms and reduce risk.

Sources and selection criteria

We searched Embase, Medline, the Cochrane Central Register of Controlled Trials, and Web of Science using the terms “orthostatic hypotension,” “postural hypotension,” “orthostatic intolerance,” and “postural intolerance.” We also used personal archived references, which included our published work and National Institute for Health and Care Excellence (NICE) guidelines.

How common is it?

The prevalence of postural hypotension increases with age. One in five community-dwelling adults over 60 years old and one in four people in long term residential care have postural hypotension, as per a systematic review and meta-analysis (26 studies, >25 000 people). 5 Two large …

Dorothy J. Irvin, DNS, APRN, BC; Marilyn White, MSN, RN

Geriatr Nurs. 2004;25(2)

  • Abstract and Introduction
  • Inconsistencies in OH Assessment
  • Nursing Implications
  • Recommendations
  • Conclusion
  • References

Recommendations

Have the patient lie supine for 10 minutes and obtain blood pressure and HR. A preponderance of the literature reviewed used 5-10 minutes in the supine position as the baseline measurement. However, questions still remain regarding optimal baseline measurement, and further research is needed. Thus, the 10-minute supine time frame seems the best approach at this time.

Take blood pressure and HR immediately after the patient arises and ask about dizziness. The literature supports the idea that HR assessment will aid in differential diagnosis. [6] HR increases 10-15 bpm normally on rising; [23] in OH, HR may increase (with a concomitant fall in blood pressure) within a range of 15-30 bpm. [1]

Grubb reported that, as patients arise, orthostatic stability usually takes place in less than 1 minute. [24] It seems important to note any immediate fall in blood pressure and increase in HR because, even though the time interval to recovery is very small, an opportunity for mishap (eg, a fall) does exist. Kunert [8] said the presence of symptoms, such as dizziness, might be more clinically important than a change in pressure reading. Further, among elderly patients, the baroreceptor response time may be blunted. [1] Thus, although these patients may not be experiencing true OH, they may have a short period of dizziness and imbalance. (This situation presents an ideal teaching moment regarding fall prevention.)

After the patient maintains an upright posture for 3 minutes, obtain blood pressure and HR again. In the literature, standing times varied, but 2-3 minutes were the most common. Engstrom [1] said, “If blood pressure is assessed for less than 2 minutes following postural change, the degree of hypotension may be overstated.” However, taking into consideration individual variances (eg, age related) in physiological response times, the 3-minute time period would seem more accurate.

How to diagnose orthostatic hypotension

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A new study led by Johns Hopkins researchers suggests that testing for the presence of orthostatic hypotension, a form of low blood pressure, be performed within one minute of standing after a person has been lying down. Current guidelines recommend taking the measurement three minutes after a person stands up.

“Our findings suggest that a blood pressure assessment within the first minute is a better way to assess health risks due to orthostatic hypotension and that waiting three minutes might miss at-risk status,” says Stephen Juraschek, M.D., Ph.D., a general internal medicine fellow at the Johns Hopkins University School of Medicine and the research paper’s first author.

A report of the study, published July 24 in JAMA Internal Medicine, suggests revising current guidelines in use since the late 1990s.

Orthostatic hypotension (OH), sometimes called postural hypotension, is a common medical condition in older adults, marked by dizziness, lightheadedness, and even fainting when they stand up. Clinically, a person is diagnosed with OH when systolic blood pressure (the top number in a blood pressure reading) drops by at least 20 mmHg during transition from lying down to standing up, or when diastolic blood pressure (the bottom reading) drops by at least 10mmHg within three minutes after standing.

While a healthy person’s blood pressure will return to their usual readings (baseline) almost immediately after such a test, blood pressure for people with OH will linger at lower values for a while. Although sometimes related to medication side effects, anemia or dehydration, OH in many cases has unknown causes. It may increase risk of falls and strokes, which can be lethal.

The current three-minute measurement threshold was implemented after a review of studies and a consensus statement from the American Academy of Neurology in the late 1990s. This statement was later reiterated in 2011. In practice, however, clinicians often do not wait the recommended three minutes to measure blood pressure due to time constraints, says Juraschek.

To learn whether waiting or not waiting for the three-minute threshold made any difference in risk assessment, Juraschek and his team analyzed blood pressure data already gathered on more than 15,000 people ages 45 to 64 during the Atherosclerosis Risk in Communities Study (ARIC), conducted from 1987 to 1989.

For their study, the research team focused on data taken from 11,429 participants who had at least four orthostatic hypotension measurements over time, and looked for any links between measurement times and falls, fractures, fainting and car crashes, all identified by active surveillance of participants’ hospitalizations and related Medicare and Medicaid claims data from 1991 to 2013. The study also looked at time of measurement in association with death, determined based on hospital discharge records, coroner reports, the National Death Index and next-of-kin interviews.

Of the participants, 54 percent (6,211 of 11,429) were women and 26 percent (2,930) were black, with an average age of 54. Nearly 10 percent (1,138) of participants self-reported a history of dizziness upon standing.

The researchers found that measurements taken within 30 seconds of standing were associated with the highest rates per 1,000 person-years of fracture (18.9), fainting (17.0) and death (31.4). Measurements taken within one minute were associated with the highest rate of falls (13.2 per 1,000 person-years) and car crashes (2.5). Measurements taken within 30 seconds were associated with the greatest proportion, 13.5 percent, of self-reported dizziness.

Juraschek said the findings support the idea that OH assessments performed within one minute of standing are most strongly related to self-reported dizziness and individual adverse outcomes.

“If someone comes into the clinic with dizziness, we try to assess his/her risk of falling or other consequences of dizziness in the future,” says Juraschek. “These results show that assessing OH within the first minute not only is OK, but also makes a lot of sense because it’s more predictive of future falls.”

Current treatments for chronic OH include physical therapy to improve balance, lifestyle changes including drinking more fluid and eating smaller meals, altering the environment (such as using grip bars), coaching patients how to safely stand up, and changing or stopping medications, especially sedatives or certain antidepressants, that are thought to be associated with OH.

Other authors on this paper include Lawrence J. Appel, Edgar R. Miller III and Elizabeth Selvin of Johns Hopkins Medicine, Natalie Daya and Andreea M. Rawlings of the Johns Hopkins Bloomberg School of Public Health, B. Gwen Windham and Michael E. Griswold of The University of Mississippi, and Gerardo Heiss of The University of North Carolina at Chapel Hill.

Juraschek is supported by a National Institute of Diabetes and Digestive and Kidney Diseases T32DK007732-20 Renal Disease Epidemiology Training Grant. The Atherosclerosis Risk in Communities Study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute contracts (HHSN268201100005C, HHSN268201100006C, HHSN268201100007C, HHSN268201100008C, HHSN268201100009C, HHSN268201100010C, HHSN268201100011C and HHSN268201100012C). The authors thank the staff and participants of the ARIC study for their important contributions. Elizabeth Selvin was supported by National Institute of Diabetes and Digestive and Kidney Diseases grants K24DK106414 and 2R01DK089174.