Learn about the causes, treatment options, and potential dangers of orthostatic hypotension. Explore its occurrence in the 20s, including symptoms

Orthostatic Hypotension

Humza Khizer

Overview

Orthostatic hypotension is also called postural hypotension. It is defined as a fall in systolic blood pressure of 20 mm Hg or more, or diastolic blood pressure of 10 mm Hg or more, within 3 minutes of standing<a href="#accordion">[2]</a>. The drop essentially occurs with a change in position, that is standing up after lying down or sitting. 
&nbsp;

As the condition is defined by the drop in blood pressure, it is necessary to first understand what blood pressure is. Blood pressure is essentially a measure of the force of blood against artery walls as the heart pumps blood through the circulatory system. Blood pressure includes two components<a href="#accordion">[3]</a>:

<ul>
	<li>Systolic: This is a measure of arterial pressure when the heart beats and fills your arteries with blood.</li>
	<li>Diastolic: Diastolic blood pressure is a measure of arterial pressure when the heart is at rest, or between heartbeats. 
	&nbsp;</li>
</ul>

Healthcare practitioners record blood pressure as systolic over diastolic. Healthy blood pressure is defined as a reading of 120/80 mmHg or below<a href="#accordion">[3]</a>. Whereas, a reading below 90/60 mmHg is defined as low blood pressure or hypotension<a href="#accordion">[5]</a>.

While there is no set limit for orthostatic hypotension, doctors&nbsp; define it as a sustained decrease in systolic blood pressure of a minimum of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg, within three minutes of standing after lying down for five minutes or at a 60-degree angle on the tilt table. This sudden fall in blood pressure is usually due to a failure of the autonomic reflex, loss of volume of fluids in the body, or an adverse reaction to any drug.

Symptoms of the condition are related to cerebral hypoperfusion (less blood supply to the brain tissue). However, patients can present asymptomatically as well. It should be also kept in mind that the rate of morbidity and mortality is high in such patients because of the reported falls, which in turn lead to recurrent hospital admissions<a href="#accordion">[1]</a>.

Orthostatic hypotension can cause dizziness or lightheadedness, and even fainting. Rarely, orthostatic hypotension is caused by something obvious, such as dehydration or excessive bed rest. Chronic orthostatic hypotension is usually a sign of another underlying health condition, hence, the treatment varies accordingly<a href="#accordion">[3]</a>.

Studies show that the prevalence of orthostatic hypotension is directly proportional to your age. According to the recorded data, orthostatic hypotension is seen to be most prevalent in patients aged 65 years or older, mostly due to impaired baroreceptor (receptors that sense pressure) sensitivity. In this age group, the prevalence can be as high as 18.2%<a href="#accordion">[1]</a>. A systematic review and meta-analysis of 26 studies, with over 25&thinsp;000 people, concluded that one in every five adults over 60 years of age based in the community and four people living in long-term residential homes have orthostatic hypotension<a href="#accordion">[1]</a>. Furthermore, two large population-based studies conducted in the US reported orthostatic hypotension in less than 5% of people aged between 45-49 years, around 15% in people aged 65 and 69 years old, and more than 25% in people over 85 years old<a href="#accordion">[1]</a>.

According to the Frank-Starling curve, standing up from a supine (lying down) position causes the pooling of around 300 mL to 800 mL of blood in the lower extremities (lower limbs). This phenomenon leads to a decreased return of blood to the heart, which in turn causes a decrease in cardiac output. Physiologically, the human body is designed to overcome this with an increase in sympathetic (flight and fight mode) tone and a decrease in vagal (resting mode) tone. This response is called the baroreceptor reflex. An increase in the sympathetic outflow increases the peripheral vascular resistance, which in turn increases the venous return (blood coming back to your heart for oxygenation) and the cardiac output, restricting the fall in your blood pressure. Symptoms of orthostatic hypotension arise when the patients lack this compensatory mechanism. 
&nbsp;

&nbsp;Based on the response to the shift in the body&rsquo;s position, orthostatic hypotension is divided into three types<a href="#accordion">[1]</a>:

<ol>
	<li>Initial Orthostatic Hypotension - A drop in systolic blood pressure of 40 mm Hg or more, or a diastolic blood pressure drop of 20 mm Hg or more within 15 seconds of standing is called initial orthostatic hypotension.</li>
	<li>&quot;Classic&quot; Orthostatic Hypotension - The drop in blood pressure occurs within three minutes of standing.</li>
	<li>&quot;Delayed&quot; Orthostatic Hypotension - The drop in blood pressure occurs after three minutes 
	.</li>
</ol>

Orthostatic hypotension is also divided, based on the etiological factors, into neurogenic and non-neurogenic<a href="#accordion">[2]</a>.

<ul>
	<li>Neurogenic Orthostatic Hypotension (nOH) is essentially a subtype of orthostatic hypotension in which there is an improper regulation of standing blood pressure due to autonomic dysfunction. Several primary and secondary causes of this disease exist. Patients may present with versatile symptoms making diagnosis difficult. 
	&nbsp;</li>
	<li>Non-neurogenic Orthostatic Hypotension results from a reduced cardiac output with or without vasoconstriction, and in the absence of a primary autonomic disorder. It is crucial to know that there are other types of low blood pressure that may present like orthostatic hypotension, but need to be differentiated. Such conditions include 
	&nbsp;</li>
	<li>&nbsp;Postprandial Hypotension</li>
</ul>

This specific fall in blood pressure takes place around 1 to 2 hours after eating. It usually affects older adults, especially those who have high blood pressure or an autonomic nervous system disease such as Parkinson&#39;s disease. To avoid this, small, low-carbohydrate meals are advised. Moreover, doctors recommend drinking as much water as possible and avoiding alcohol. 
&nbsp;

<ul>
	<li>Neurally Mediated Hypotension</li>
</ul>

In this condition, the blood pressure drops after standing for long durations and mostly affects young adults and children. Pathology includes a miscommunication between the heart and brain. 
&nbsp;

<ul>
	<li>Multiple System Atrophy With Orthostatic Hypotension:</li>
</ul>

The condition is often termed the Shy-Drager Syndrome, - a rare disorder that affects the autonomic nervous system that controls involuntary functions such as blood pressure, heart rate, breathing and digestion. Patients may complain of very high blood pressure while lying down. 
&nbsp;

Signs and Symptoms

Patients with orthostatic hypotension typically report a drop in blood pressure and severe symptoms in the mornings. This is because your blood pressure is at its lowest in the morning. However, some people stay asymptomatic. Many have also reported hot temperatures such as the weather, a fever or a hot shower to aggravate their symptoms.

The most alarming sign of orthostatic hypotension is dizziness or lightheadedness as soon as you stand, which subsides once you sit or lie down. Other signs include<a href="#accordion">[3]</a>: 
&nbsp;

<ul>
	<li>Blurry vision.</li>
	<li>Chest pain, shoulder pain or neck pain.</li>
	<li>Difficulty concentrating.</li>
	<li>Weakness.</li>
	<li>Headaches.</li>
	<li>Heart palpitations (heart beating abnormally fast).</li>
	<li>Nausea.</li>
	<li>Shortness of breath(dyspnea) 
	&nbsp;</li>
</ul>

Causes

Orthostatic hypotension can be caused by either a pre-existing medical condition or the use of certain drugs<a href="#accordion">[6]</a>. Medical conditions that can cause low blood pressure include: 
&nbsp;

<ul>
	<li>Pregnancy</li>
</ul>

A woman&rsquo;s body changes during pregnancy and causes the blood vessels to expand faster. These changes may cause a drop in blood pressure. This lowering of blood pressure is usually seen in the first 24 weeks of pregnancy and subsides after giving birth. 
&nbsp;

<ul>
	<li>Heart And Heart Valve Conditions</li>
</ul>

Conditions like a heart attack, heart failure, heart valve disease and a low heart rate (bradycardia) can cause the blood pressure to drop. 
&nbsp;

<ul>
	<li>Endocrine Disorders (Hormone-related Diseases)</li>
</ul>

If you have a disease that directly or indirectly affects your parathyroid or adrenal glands, like Addison&#39;s disease, it may in turn cause the blood pressure to drop. Moreover, low blood sugar (hypoglycemia) and diabetes may lower your blood pressure to give symptoms of orthostatic hypotension. 
&nbsp;

<ul>
	<li>Dehydration</li>
</ul>

When your body doesn&#39;t have enough water, the blood volume drops, and lowers blood pressure. Fever, vomiting, severe diarrhoea and extreme exercise routines are a few factors that lead to dehydration. 
&nbsp;

<ul>
	<li>Blood Loss</li>
</ul>

Losing a lot of blood due to an injury or any condition that causes internal bleeding, can reduce your blood volume, which in turn leads to a severe drop in blood pressure. 
&nbsp;

<ul>
	<li>Severe Infection (Septicemia)</li>
</ul>

When an infectious pathogen enters the body by the bloodstream, it can lead to a fatal drop in blood pressure., The condition is called a septic shock. 
&nbsp;

<ul>
	<li>Severe Allergic Reaction (Anaphylaxis)</li>
</ul>

An allergic reaction can also cause a dramatic drop in blood pressure. 
&nbsp;

<ul>
	<li>Malnutrition</li>
</ul>

If your diet lacks a good quantity of vitamin B-12, folate and iron, it can hinder the production of red blood cells, giving rise to a condition referred to as anaemia. This in turn leads to hypotension. 
&nbsp;

There are no screening tests for orthostatic hypotension in particular. However, a keen observation of your blood pressure and situation when it gets disrupted might help your healthcare practitioner to reach a diagnosis. 
&nbsp;

Diagnosis

Your doctor will record your blood pressure while you&rsquo;re seated, lying down and standing in order to see any difference. Any of these tests might also be ordered<a href="#accordion">[4]</a>: 
&nbsp;

<ul>
	<li>Blood tests to rule out possibilities of <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes </a>and <a href="https://merisehat.pk/disease/anemia">anaemia</a>.</li>
	<li>Echocardiogram to evaluate the heart&rsquo;s pumping.</li>
	<li>Electrocardiogram (ECG) to check for any irregularities in the heart&rsquo;s rhythm.</li>
	<li>Exercise stress test to evaluate your heart rate under physical exertion.</li>
	<li>A tilt table test to safely record your blood pressure, heart rate and heart rhythm while you are laid down on a table which moves from horizontal to vertical 
	&nbsp;</li>
</ul>

Treatment

If you have episodes of orthostatic hypotension, your healthcare provider will first try to determine if you have another condition or disease that is causing it. In many cases, treating the primary disease causing orthostatic hypotension will cure it. Treatment is mostly aimed at the cause rather than the low blood pressure.

If you&rsquo;re taking a medication that&rsquo;s causing orthostatic hypotension as a side effect, your doctor might discontinue it or taper the dose of the drug. Moreover, lifestyle changes such as drinking more water may be advised. However, if these interventions are unable to improve your orthostatic hypotension, then medications that increase your blood volume and pressure may be prescribed. These include<a href="#accordion">[1]</a> <a href="#accordion">[6]</a>:

<ul>
	<li>Droxidopa</li>
	<li>Fludrocortisone</li>
	<li>Midodrine</li>
	<li>Pyridostigmine 
	&nbsp;</li>
</ul>

However, adjusting some mundane things in your routine can significantly improve your orthostatic hypotension.&nbsp;

&nbsp;

<ul>
	<li>Keep Yourself Hydrated</li>
</ul>

The method is as simple as it gets - drink enough fluids. Diarrhoea or vomiting can lead to an excessive loss of fluids. This loss has to be attended to and revived as soon as possible. Moreover, quit alcohol as it is known to aggravate orthostatic hypotension.

&nbsp;

<ul>
	<li>Using More Salt</li>
</ul>

Salt is known for increasing your blood pressure. However, you should always consult a doctor first.

&nbsp;

<ul>
	<li>Give Yourself A&nbsp;Minute</li>
</ul>

When you are planning to get out of bed, it is wise to first sit on the edge of the bed for a minute before you decide to stand. 
&nbsp;

<ul>
	<li>Change Your Head side</li>
</ul>

Try sleeping with the head side of your bed slightly elevated. 
&nbsp;

<ul>
	<li>&nbsp;Compression Stockings</li>
</ul>

Stockings help in promoting your circulation and preventing the pooling of fluid in your legs and swelling. 
&nbsp;

If your orthostatic hypotension does not subside and is allowed to persist, it can cause serious complications. These include<a href="#accordion">[6]</a>: 
&nbsp;

<ul>
	<li>Falls</li>
</ul>

Falling is a very considerable outcome due to fainting after a drop in blood pressure.

<ul>
	<li><a href="https://merisehat.pk/disease/stroke">Stroke</a></li>
</ul>

The variation in the blood pressure from the constant changes in position in orthostatic hypotension can lead to stroke as there is a reduced blood supply to the brain.

<ul>
	<li>Cardiovascular Diseases</li>
</ul>

Orthostatic hypotension can be a risk factor for cardiovascular diseases and complications, such as chest pain, heart failure or heart rhythm problems. 
&nbsp;

Parameters that increase someone&rsquo;s risk to get a particular disease are called risk factors. Risk Factors for orthostatic hypotension include<a href="#accordion">[6]</a>:

<ul>
	<li>Age</li>
</ul>

Orthostatic hypotension is commonly seen in people aged 65 years and older.

<ul>
	<li>Medications</li>
</ul>

Medications which are used to treat high blood pressure or heart disease, for example, diuretics, alpha-blockers, beta-blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors and nitrates can lower your blood pressure excessively and cause orthostatic hypotension. Moreover, medications that increase your risk include drugs used to treat Parkinson&#39;s disease, antidepressants, antipsychotics, muscle relaxants and medications to treat erectile dysfunction.

<ul>
	<li>Certain Diseases</li>
</ul>

Some diseases can cause low blood pressure. These include certain heart conditions, such as valvular diseases, heart attack and heart failure.

<ul>
	<li>Heat Exposure</li>
</ul>

A hot surrounding induces excessive sweating which can lead to dehydration and lowered blood pressure, a trigger for orthostatic hypotension.

<ul>
	<li>Bed Rest</li>
</ul>

If you stay in bed for a long time, the weakness due to excessive rest and lack of activity can lead to orthostatic hypotension.

<ul>
	<li>Alcohol</li>
</ul>

Drinking alcohol is studied to be a potential risk factor for orthostatic hypotension. 
&nbsp;

To prevent orthostatic hypotension, the following steps can be taken<a href="#accordion">[7]</a>: 
&nbsp;

<ul>
	<li>Temperature Regulation</li>
</ul>

Avoid taking baths with extremely hot water.

<ul>
	<li>Engage in Activity</li>
</ul>

You should build a habit of moving your feet if you are in a position to stand for prolonged periods. Isometric exercises are also recommended which include squeezing a soft rubber ball and clenching &amp; unclenching your hands to raise blood pressure before you stand.

<ul>
	<li>Support Blood Pressure</li>
</ul>

Wearing compression stockings or an abdominal belt might improve your blood circulation and pressure.

<ul>
	<li>Quit Alcohol</li>
</ul>

Since alcohol consumption is a known risk factor , it is best to quit this habit. Reach out to your healthcare practitioner to guide you on various options to help with quitting and recovery. 
&nbsp;

A study was done to compare the delayed variant of orthostatic hypotension with the classical one. The study found that people with classical orthostatic hypotension are older, and most probably have supine hypertension, autonomic dysfunction, Parkinson&#39;s disease, pacemaker-treated arrhythmia, and lower glomerular filtration rate. Moreover, classical orthostatic hypotension was linked with an increased level of vasopressin and epinephrine during head-up tilt. These findings suggested that the classical variant, compared with the delayed form, is mostly associated with more severe abnormalities of both autonomic and neuroendocrine disorders and can be declared as an advanced and severe condition<a href="#accordion">[8]</a>. 
&nbsp;

Key Points

<ul>
	<li>Also called postural hypotension, orthostatic hypotension is defined as a fall in systolic blood pressure of 20 mm Hg or more, or diastolic blood pressure of 10 mm Hg or more, within 3 minutes of standing. The drop essentially occurs with a change in position, that is standing up after lying down or sitting..</li>
	<li>Orthostatic hypotension can be described as a mild condition in terms of severity with short-lived episodes</li>
	<li>Blood pressure is essentially the measure of the force of blood against your artery&rsquo;s wall as the heart pumps blood through the circulatory system. Your doctor measures the blood pressure as systolic over diastolic.Healthy blood pressure for the majority is below 120/80 mmHg</li>
	<li>Studies show that the prevalence of orthostatic hypotension is directly proportional to your age.The prevalence may be as high as 18.2% within the mentioned age range.</li>
	<li>A systematic review and meta-analysis of 26 studies, which had over 25&thinsp;000 people, concluded that one in every five adults over 60 years of age based in the community and four people living long-term in residential homes have orthostatic hypotension</li>
	<li>There can be essentially three types of responses - initial, classical or delayed hypotension.</li>
	<li>Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension in which there is an improper regulation of standing blood pressure due to autonomic dysfunction</li>
	<li>The most alarming sign of orthostatic hypotension is dizziness or lightheadedness as soon as you stand, which subsides once you sit or lie down. Other signs include blurry vision, chest pain, shoulder pain or neck pain and difficulty concentrating.</li>
	<li>Orthostatic hypotension can be caused by either a pre-existing medical condition or the use of certain drugs.</li>
	<li>There are no screening tests for orthostatic hypotension in particular. However, a keen observation of your blood pressure and situation when it gets disrupted might help your healthcare practitioner to reach a diagnosis.</li>
	<li>Your doctor will record your blood pressure while you&rsquo;re seated, lying down and standing in order to see any difference</li>
	<li>Diagnostic tests include blood tests, echocardiogram, and ECG</li>
	<li>In many cases, treating the primary disease causing orthostatic hypotension will cure it.</li>
	<li>If you&rsquo;re taking a medication which has orthostatic hypotension as a side effect, your doctor might discontinue it or taper the dose of the drug</li>
	<li>Rarely, drugs are used to treat orthostatic hypotension such as droxidopa, fludrocortisone, pyridostigmine and midodrine.</li>
	<li>Alcohol consumption should be stopped as it is known to aggravate orthostatic hypotension.</li>
	<li>Salt is known for increasing your blood pressure, however, you should always consult a doctor first.</li>
	<li>It is wise to first sit on the edge of the bed for a minute before you decide to stand.</li>
	<li>Try sleeping with the head side of your bed being slightly elevated.</li>
	<li>If your orthostatic hypotension does not subside and is allowed to persist, it can cause serious complications like falls, stroke and cardiovascular diseases.</li>
	<li>Risk factors for orthostatic hypotension include age above 65 years, hypertension drugs, use of antidepressants and excessive bedrest.</li>
	<li>Preventive measures include engaging in activity and temperature regulation.</li>
	<li>Latest findings suggested that the classical variant of the orthostatic hypotension, compared with the delayed form, is mostly associated with more severe abnormalities of both autonomic and neuroendocrine disorders and can be declared as an advanced and severe condition. 
	&nbsp;</li>
</ul>

[1] Ringer M, Lappin SL. Orthostatic Hypotension. [Updated 2022 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[2] Kalra, D. K., Raina, A., & Sohal, S. (2020). Neurogenic Orthostatic Hypotension: State of the Art and Therapeutic Strategies. Clinical Medicine Insights. Cardiology, 14, 1179546820953415. https://doi.org/10.1177/1179546820953415.

[3] Orthostatic hypotension (postural hypotension). Cleveland Clinic.

[4] Orthostatic hypotension (postural hypotension). Mayo Clinic.

[5] Low blood pressure (hypotension). Mayo Clinic.

[6] Orthostatic hypotension (postural hypotension). Mayo Clinic.

[7] Orthostatic hypotension: Causes, symptoms, and prevention. Medical News Today.

[8] Torabi, P., Ricci, F., Hamrefors, V., Sutton, R., & Fedorowski, A. (2020). Classical and Delayed Orthostatic Hypotension in Patients With Unexplained Syncope and Severe Orthostatic Intolerance. Frontiers in cardiovascular medicine, 7, 21.