A case of hypotension H.pptx

the presentation discuss the importance of diagnosis and treatment of hypotension in a clinical scenario

1. A case of hypotension Haytham Soliman Ghareeb Lecturer of cardiovascular medicine Fayoum university

2. 25 year old female Not diabetic or hypertensive Average built BMI 23 On continuous diet Came complaining of low blood pressure

3. Condition started one year ago soon after she started her diet Dizziness, palpitation and fatigue specially when she wakes up The condition partially improve during the day It also improves when she lies flat She sought medical advice in a primary health care center

4. Primary health care center Her blood pressure was 90/50 mmHg in sitting position and one minute after standing Her ECG was normal Her physical examination was normal Ordered echocardiogram was normal Her CBC was within normal range She was given oral Etilefrine -HCL 5mg tab BID

5. Patient partially improved but she stopped the treatment due to headache Symptoms regain soon after The condition was exaggerated and she needed IV fluid for this hypotension once at a local hospital Then she came to our hospital seeking medial advice What should we do?

6. Overview about hypotension

7. Definition Its is decrease in blood pressure that cause hypo perfusion of vital organs specially the brain and heart Its not always related to a number so (90/60 mmHg) is not hypotension in asymptomatic individual Usually a blood pressure below 80/50 mmHg cause hypotension A drop in systolic blood pressure of 20mmHg can cause hypotension symptoms Severe hypotension can cause serious hypo-perfusion and shock

8. Mechanism hypotension decrease in cardiac output dilation of blood vessels decrease in blood volume Inhibition of brain centers that control blood pressure I mpairment of the autonomic nervous system

9. Causes of hypotension

10. Dehydration: – Even minor dehydration can cause hypotension – This effect is exaggerated in elderly people Blood loss: – bleeding cause hypotension via volume depletion – major bleeding cause sever hypotension and shock Cardiac disease: – obstructive valvular lesions – myocardial infacrtion – advanced heart failure – bradychardia – myocarditis – cardiotoxic drugs

11. Severe allergic reactions: Reaction cause capillary vasodilation and blood pressure to drop Pancreatitis: Fluids enters the inflamed tissues around the pancreas concentrating the blood and reducing its volume Severe infection: Any infections that enter the bloodstream can cause potentially fatal drops in blood pressure Endocrinal disorders: – hyper and hypo thyroidism – Diabetes – Postgastrectomy – primary hypoaldosteronism – pheochromocytoma

12. Pregnancy : – Hypotension is due to blood pulled into fetal circulation – This condition recovers after delivery Medications : – Diuretics , beta-blockers, alpha-blockers, calcium channel blockers – Certain antidepressants ( e.g. tricyclic ) – Drugs for Parkinson disease (carbidopa and levodopa ) – PDE5 inhibitor ( Sildenafil) specially when combined with nitroglycerin

13. Classification Postural or orthostatic hypotension (OH ) Postprandial hypotension Neurally mediated hypotension Multiple system atrophy with orthostatic hypotension

14. Postural or orthostatic hypotension (OH ) Decrease in systolic BP≥20 mm Hg or decrease in diastolic BP≥10 mm Hg within 3 minutes of standing or Similar drop in BP within 3 minutes in a head up position on tilt table test at angle ≥60° strongly age-dependent, with prevalence ranging from 5% to 11% in middle age to 30% or higher in the elderly Its due to failure of neuro and chemoreceptor mechanisms that counteract decrease of blood volume during standing

15. Sequence Rapid decrease in venous return to heart Reduce ventricular filling ↓ CO ↓ BP Provoke compensatory mechanisms ↓ Parasympathetic ↑ sympathetic ↑ Peripheral resistance ↑ venous return Maintain BP with Small fall in SBP (5-10mmHg) ↑ Diastolic Bp (5-10mmHg) ↑ Pulse rate 10-25 beat/min Absent

16. Postprandial hypotension : – Occurs when blood pressure drops suddenly after eating – due to pooling of blood in the intestine for digestion – More common than postural hypotension – Occurs mainly in the elderly – Risk factors includes Parkinson disease, autonomic neuropathy

17. Neurally mediated hypotension: Occurs when blood pressure drops after standing for a long period of time Multiple system atrophy with orthostatic hypotension: – Also known as Shy- Drager syndrome – Progressive damage to the autonomic nervous system – It causes hypotension when standing and hypertension when lying down.

18. Symptoms and signs Orthostatic Hypotension and Neurally Mediated Hypotension : - Dizziness or light-headedness - Blurred vision - Confusion - Weakness - Fatigue - Nausea Orthostatic hypotension happen within a few seconds or minutes of standing up and disappear with sitting or lying down NMH occur after standing for a long time or in response to a stressful situation. The drop in blood pressure doesn't last long and often disappear after sitting down.

19. Diagnostic tools other than blood pressure measurement Laboratory work up: CBC , blood electrolyte measurement, thyroid profile, cortisol levels, blood and urine cultures if infection is suspected Radiologic studies: ECG, echocardiogram, Holter monitor, lower limbs vemous duplex , CT scan of the chest and abdomen and tilt-table tests

20. Treatment Mainly treatment of the cause ( endocrine disorders, heart failure, medication side effects) Mild dehydration is treated with oral fluids and electrolytes Moderate-to-severe dehydration is usually treated in the hospital or emergency room with IV fluids and electrolytes

21. Drug therapy Fludrocortisone – very potent mineralocorticoid that Increase reabsorption of sodium from distal renal tubules – Recommended as first-line drug therapy in dehydration – Given as 0.1 mg/day , increased by 0.1 mg per week; the maximum daily dose is 1 mg/day .

22. Midodrine : – Alpha agonist that increases arteriolar and venous tone – Rise standing , sitting, and supine systolic and diastolic blood pressure in patients with orthostatic hypotension – Dose is 10 mg three times per day during daytime (maximum dose is 40 mg/day ) – In the prevention of hemodialysis-induced hypotension (unlabeled use), 2.5 to 10 mg is given 15 to 30 minutes prior to a dialysis session – The major side effect of this drug is supine hypertension

23. Norepinephrine: – A vasoactive agent that stimulates beta and alpha-adrenergic receptors – It increased contractility and heart rate and thereby systemic blood pressure – IV infusion in shock patients with an initial dose of 8 to 12 mcg/min Octreotide: – A somatostatin analogue that inhibits release of gastrointestinal peptides, some of which may cause vasodilation – Subcutaneous doses given 30 minutes before a meal may be used to reduce postprandial orthostatic hypotension – Octreotide does not increase supine hypotension

24. Prevention Water Intake : – Combat dehydration and increases blood volume – Dehydrating drinks like alcohol and coffee should be avoided – Triggers such as a high temperature environment must be avoided Compression stockings: – They reduce pooling of blood in the legs and can prevent hypotension Body positions: – Patients should sit up and breathe deeply as they get out of bed in the morning or when standing up from a sitting position – Dorsiflexing their feet first and even crossing the legs while upright can be helpful.

25. Back to our patient We took a carful history and we discovered that: – She do not drink more than 1 liter of fluid/day – She drinks a lot of coffe e and tea – In her diet she is taking a tricyclic antidepressant to help her reduce weight – symptoms occur more when changing position form siting to prone

26. Examination and laboratory tests She had a baseline BP of 90/56 mm Hg in sitting position She has a marked drop of blood pressure after 3 min of standing reduced to 70/50 with beginning of symptoms She had normal thyroid functions, cortisol level, kidney functions and electrolytes

27. Treatment She was advised to: – Drink at least 3 liters of fluid/day – To stop coffee – To stop antidepressant At follow up: – Symptoms improved markedly but still present only in sudden rise from sitting – She refused to take any other medications – She was advised to wear an elastic stoking with disappearance of the symptoms

28. Take home message Hypotension is an important symptom with many causes It is not related to a fixed BP level BP must be measured both sitting and standing in all cases Proper history about patient hydration and drugs is a must Further investigations are guided by clinical presentation Prevention comes first Don’t begin drug therapy before knowing the cause of hypotention

29. Thank you