Orthostatic Hypotension
It is absolutely critical to establish a reproducible supine blood pressure before checking standing blood pressure. Otherwise an incorrect diagnosis may be made. Lying BP should therefore be repeated until a reproducible reading is obtained. Standing BP and heart rate should then be measured immediately on standing, at 1 minute, 2 minutes, 3 minutes and 5 minutes.
Symptoms of orthostatic hypotension may include lightheadedness, darkening of vision, and inability to remain upright. Patients may also complain of so-called Coat Hanger pain. This is caused by reduced oxygen supply to muscles in the neck and shoulder girdle.
Orthostatic hypotension may be caused by:
Volume depletion e.g. by excessive sweating without adequate fluid replacement
Anaemia e.g. because of blood loss
Drugs:
• anti heart failure drugs
• anti hypertensive drugs
• anti Parkinson’s disease drugs
• anti depressant drugs
Autonomic neuropathy
Non-drug treatment of Orthostatic hypotension (With thanks to Professor Chris Mathias, Imperial College London):
Correct:
• hypovolaemia
• anaemia
Avoid:
• drugs likely to lower blood pressure
• standing up quickly
• straining at stool
• hot baths
• large meals – especially refined carbohydrate rich food
• excessive alcohol
• prolonged standing
• severe exertion
Introduce:
• head-up sleeping – raise the head of the bed by 10º
• small frequent meals
• increased salt intake
• judicious exercise
• counter physical manoeuvres
• oral water ingestion – rapidly drinking 400 mls significantly increases BP in autonomic failure
Consider:
• compression garments – compression socks are not very effective, and full length stockings tend to slip down, so compression tights are the best option.
In the UK compression tights can be dispensed on prescription by your GP. A list of compression tights available on FP10 prescription can be seen on the NHS Electronic Drug Tariff. Simply search for TIGHTS.
Products include:
Solidea Dynamic – SUITABLE FOR MEN
The class (1, 2 or 3) of tights indicates the amount of compression they create. Class 1 offer 18-21 mmHg compression, Class 2 offer 23-32 mmHg, and Class 3, if available, offer 34-46 mmHg. The higher the compression the more difficult the tights are to put on. Class 2 tights are usually required, but it may be advisable to try Class 1 first if you have not worn compression tights before.
Mediven have helpfully produced an online prescription form. Measurements should be taken by a suitably qualified person – usually the Practice nurse. This form needs to be countersigned by your GP.
To help your GP it is advisable to look at the tights available and make a selection. Bring that information along with you to your consultation. Your GP may, of course, have his/her own favourite brand.
• abdominal binders: Our experience is that abdominal binders are at least as effective as compression stockings, and are much easier to put on. There are several brands available to buy. Having tried a number of them on patients our current favourite is this one. These work by reducing splanchnic venous pooling in the abdomen.
• anti-gravity suit if very symptomatic and all else fails
Drug treatment of Orthostatic hypotension:
Volume expanders:
Fludrocortisone – low dose, starting with 50 mcg note increasing the dose gradually every six weeks to a maximum of 200 mcg or 300 mcg note if required
Flurbiprofen – a Non Steriodal Anti Inflammatory Drug may be used in conjunction with Fludrocortisone to enhance fluid retention
Adrenoreceptor agonists:
Midodrine – post-ganglionic alpha agonist.
Ephedrine – beta agonist. Use with care tds with last dose early evening
Specific targeting:
Octreotide – for post-prandial hypotension
Desmopressin – with Fludrocortisone if nocturnal polyuria
Erythropoietin – for refractory anaemia in renal failure
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