Family of disorders that produce symptoms of cerebral hypoperfusion in response to postural challenge; they involve the dysfunction or disregulation of postural reflexes
What 4 syndromes cause Orthostatic intolerance?
Orthostatic hypotension
delayed orthostasis
postural orthostatic tachycardia syndrome
neurally mediated hypotension (vasovagal reflex or reflex syncope)
What are the symptoms of orthostatic Intolerance
Dizziness or lightheadedness
Visual blurring
Darkening of visual fields
Generalized weakness
Loss of conciousness
immediate orthostasis is defined as a postural decrease in BP of >____mmHg for systolic BP and a decrease of >____ mmHg for diastolic BP
SBP>20 mmHg
DBP>10 mmHg
Immediate Orthostasis can occur with ______ insufficiency where there is inadequate tachycardial compensation or with ____ depletion where the patient becomes tachycardic but not enough to compensate.
Autonomic insufficiency
Volume depletion
What are 4 classes of medications that can cause Euvolemic orthostatic hypotension
antihypertensive agents
tricyclic agents
monoamine oxidase inhibitors
dopamine agonists
What are 2 endocrine diseases that can cause Euvolemic orhtostatic hypotension?
Adrenocortical deficiency
Pheochromocytoma
What are some Neurological conditions that can cause euvolemic orthostatic hypotension?
Parkinson's disease
multisystem failure
CNS tumor
Myelopathy
Dementia/multi-infarct
What are 3 things you can educate an orthostatic hypertension patient to do in order to reduce episodes?
Orthostatic precautions � pause at the side of the bed
Small, frequent, low carbohydrate meals- increased shunt to internal organs with large meals or meals heavy on carbs which are vasodilitory
Avoid alcohol- vasodilitor and diuretic
What type of clothing can a person with orthostatic hypotension wear to decrease symptoms?
Compressive stockings
What physical maneuvers can help prevent falls in an orthostatic hypotension pt.?
Leg crossing
isometric hand gripping
respiratory manuvers pursed lip or sniff
Exercise
Elevate the head of the bed at night (activates the RAS reducing nocturnal diuresis)
What dietary changes would you make for a patient with orthostatic hypotension?
Increase sodium in diet
What medication can you perscribe for an OH patient with anemia?
Erythropoietin- use in anemic patients less than 35% aim for normal hct
How does caffeine help pts with orthostatic hypotension?
Inihibits vasodilating effects of adenosine and increases sympathetic tone
What medications could you give a patient with OH to improve their symptoms? (5)
Florinef
Midodrine
NSAIDs
Caffeine
Erythropoietin
What med for OH should you avoid in a patient with urinary retention?
Midodrine (also dose while pt is awake)
How do NSAIDs help to raise BP?
Prostacyclin inhibition, vasoconstrictor and activation of RAS
What NSAIDs are used for OH?
Indomethacin
What is the biggest problem with medical management of OH?
BP effects of therapy are posture independent so when the patient moves to sitting or laying position their BP jumps to hypertensive state
The Goals of OH therapy are a standing SBP > ___ mmHg and a Supine BP of <___ mmHg which can be achieved with timing of midodine dosing, HOB and nocturnal nitrates
90mmHG and 180 mmHG
What med can you add at night to a patient with OH who is hypertensive at rest?
Nocturnal nitrates
Your patient is a 78 year old female who reports feeling faint at different times of the day she does not think it occurs with postural change because it never occurs directly after standing. She also has not noticed any abnormal heart flutters or palpitations, anxiousness or neurological changes. You suspect...
Delayed Orthostasis
Delayed orthostasis can be __ -__ mins after postural challenge
10-45 mins
True or false Delayed orthostasis is more likely to be associated with vasovagal symptoms
True
_____ should be considered when lightheadedness in an older individual is recurrent, consistent, persistent, but does not occur with immediate postural challenge, the patient may not recognize the postural connection
What is the most prevalent form of orthostatic intolerance
POTS
What age range does POTS present in
14-45 years old
What does POTS stand for
Postural orthostatic tachycardia syndrome
Who is more likely to get POTS men or women?
Women
What are the 4 possible pathophysiologies of POTS?
Reduction in effective circulating blood volume (ECBV) � (peripheral venous sympathetic denervatino with preserved cardiac innervation, dynamic orthostatic hypovolemia)
Acutal reduction in effective circulating blood volume- (possible renal sympathetic denervation decreased activation of RAAS, reduction in red cell mass)
Parasympathetic insufficency leading to attenuated baroreceptor responses
Primary sympathetic excess
What are some symptoms of POTS
racing heart, palpitations, anxiety, tremulousness, irritability, difficulty concentrating, difficulty focusing, sleeplessness, headache, lightheaded, fatigue, SOB, Exercise intolerance, nausea, bloating, abdominal cramping, constipation, diarrhea, cutaneous mottleing, dependent rubor, cold intolerance, heat intolerance, hear fainting, fainting, sweats, good days, bad days (I'm having a bad day b/c of this exam)
