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What Causes Orthostatic Hypotension?
Question: I am desperate to find a diagnosis for my wife of 56 years. She is 75 and has always been vigorous and in good health. For about one year, she has been getting dizzy - when standing from sitting. That was the initial symptom. Over the year, she has developed constant fatigue and weakness, practically illegible handwriting, agitation, slowness in gait. She is now anxious and is easily irritated. She las lost 25 lbs.
She has seen MDs in the following specialties with their findings noted:
ENT exam - normal.
Ultrasound of neck and head - normal.
Neurologist exam – normal - thought the dizziness came from stress.
Cervical MRI - showed mild to moderate stenosis but he did not consider it serious enough to cause the dizziness. Still thought dizziness came from stress.
Vestibular rehab – 8-10 times over several weeks – no improvement.
Endocrinologist - thyroid function normal. (She had thyroidectomy some 15 years ago.
Psychiatrist, Duke – Sought her opinion on whether this was early sign of dementia. She only thought (and still thinks) she has mild depression, prescribed Ativan.
Bone Marrow Test – normal.
Another neurological exam - normal, but - Blood pressure and pulse checked - first sitting, then standing. BP dropped 13 pts. when standing. Suggested we check this out further.
Endocrinologist again – this time, tested for adrenal insufficiency. Lab tests - test “borderline.” Decided to prescribe hydrocortisone 20 mg/day) “to see if it helps”. Have seen no difference since then. Retest also normal. Stopped taking.
Cardiologist – saw last week. He did echocardiogram -normal. Next day, Tilt-table test administered. She fainted within 10 minutes and, while he had first suspected Orthostatic Hypotension (even though the drop in BP was not below 20 every time – (it was not consistent)), his thinking switched to a diagnosis of vasovagal syncope. His instructions are for her to drink 80 - 100 ounces or more each day, add salt to her diet and vigorous exercise for legs. If she has not in improved within two months, he has given us a prescription for Florinef 0.1 mg. which we are to begin. While he asked us to give it 2 months, I plan to notify him before then that my continued taking of BP at home is showing even more drops in BP (several over 20 when sitting to standing.)
Potential diagnoses mentioned but none confirmed: Orthostatic Hypotension, Pots, adrenal insufficiency – now considering vasovagal syncope, as noted above.
I am anxious for a diagnosis but have a little problem - with an old lawyer’s mind - understanding how an ailment can be called “syncope” when the only time she has fainted was on the tilt table test.
Please let me know if you have any questions.
CURRENT MEDICATIONS
atorvastatin 20 MG tablet
Commonly known as: LIPITOR
About This Medication
Instructions: Take 20 mg by mouth daily.
Documented by XXXXXXX XXXX
levothyroxine 75 MCG tablet
Commonly known as: SYNTHROID, LEVOTHROID
About This Medication
Instructions: Take 75 mcg by mouth daily at 0600.
Documented by XXXXXXX XXXX
VITAMIN E ORAL
About This Medication
Instructions: Take by mouth.
Documented by XXXXXXX XXXX
estradiol-norethindrone 1-0.5 mg per tablet
Commonly known as: ACTIVELLA
About This Medication
Instructions: Take 1 tablet by mouth daily.
Documented by XXXXXXX XXXX
hydrocortisone 20 MG tablet
Commonly known as: CORTEF
About This Medication
Instructions: Take 20 mg by mouth daily.
Documented by XXXXXXX XXXX
sertraline 25 MG tablet
Commonly known as: ZOLOFT
About This Medication
Instructions: Take 25 mg by mouth daily.
Documented by XXXXXXX XXXX
cholecalciferol (vitamin D3) 5,000 unit tablet
Commonly known as: VITAMIN D3
About This Medication
Instructions: Take 5,000 units by mouth daily.
Documented by XXXXXXX XXXX
clonazePAM 1 MG tablet
Commonly known as: KlonoPIN
About This Medication
Instructions: Take 1 mg by mouth two (2) times a day as needed for anxiety. take 1/2 tablet in the morning and 1 tablet in the evening as needed
Documented by XXXXXXX XXXX
meloxicam 7.5 MG tablet
Commonly known as: MOBIC
About This Medication
Instructions: Take 7.5 mg by mouth daily.
Documented by XXXXXXX XXXX
She has seen MDs in the following specialties with their findings noted:
ENT exam - normal.
Ultrasound of neck and head - normal.
Neurologist exam – normal - thought the dizziness came from stress.
Cervical MRI - showed mild to moderate stenosis but he did not consider it serious enough to cause the dizziness. Still thought dizziness came from stress.
Vestibular rehab – 8-10 times over several weeks – no improvement.
Endocrinologist - thyroid function normal. (She had thyroidectomy some 15 years ago.
Psychiatrist, Duke – Sought her opinion on whether this was early sign of dementia. She only thought (and still thinks) she has mild depression, prescribed Ativan.
Bone Marrow Test – normal.
Another neurological exam - normal, but - Blood pressure and pulse checked - first sitting, then standing. BP dropped 13 pts. when standing. Suggested we check this out further.
Endocrinologist again – this time, tested for adrenal insufficiency. Lab tests - test “borderline.” Decided to prescribe hydrocortisone 20 mg/day) “to see if it helps”. Have seen no difference since then. Retest also normal. Stopped taking.
Cardiologist – saw last week. He did echocardiogram -normal. Next day, Tilt-table test administered. She fainted within 10 minutes and, while he had first suspected Orthostatic Hypotension (even though the drop in BP was not below 20 every time – (it was not consistent)), his thinking switched to a diagnosis of vasovagal syncope. His instructions are for her to drink 80 - 100 ounces or more each day, add salt to her diet and vigorous exercise for legs. If she has not in improved within two months, he has given us a prescription for Florinef 0.1 mg. which we are to begin. While he asked us to give it 2 months, I plan to notify him before then that my continued taking of BP at home is showing even more drops in BP (several over 20 when sitting to standing.)
Potential diagnoses mentioned but none confirmed: Orthostatic Hypotension, Pots, adrenal insufficiency – now considering vasovagal syncope, as noted above.
I am anxious for a diagnosis but have a little problem - with an old lawyer’s mind - understanding how an ailment can be called “syncope” when the only time she has fainted was on the tilt table test.
Please let me know if you have any questions.
CURRENT MEDICATIONS
atorvastatin 20 MG tablet
Commonly known as: LIPITOR
About This Medication
Instructions: Take 20 mg by mouth daily.
Documented by XXXXXXX XXXX
levothyroxine 75 MCG tablet
Commonly known as: SYNTHROID, LEVOTHROID
About This Medication
Instructions: Take 75 mcg by mouth daily at 0600.
Documented by XXXXXXX XXXX
VITAMIN E ORAL
About This Medication
Instructions: Take by mouth.
Documented by XXXXXXX XXXX
estradiol-norethindrone 1-0.5 mg per tablet
Commonly known as: ACTIVELLA
About This Medication
Instructions: Take 1 tablet by mouth daily.
Documented by XXXXXXX XXXX
hydrocortisone 20 MG tablet
Commonly known as: CORTEF
About This Medication
Instructions: Take 20 mg by mouth daily.
Documented by XXXXXXX XXXX
sertraline 25 MG tablet
Commonly known as: ZOLOFT
About This Medication
Instructions: Take 25 mg by mouth daily.
Documented by XXXXXXX XXXX
cholecalciferol (vitamin D3) 5,000 unit tablet
Commonly known as: VITAMIN D3
About This Medication
Instructions: Take 5,000 units by mouth daily.
Documented by XXXXXXX XXXX
clonazePAM 1 MG tablet
Commonly known as: KlonoPIN
About This Medication
Instructions: Take 1 mg by mouth two (2) times a day as needed for anxiety. take 1/2 tablet in the morning and 1 tablet in the evening as needed
Documented by XXXXXXX XXXX
meloxicam 7.5 MG tablet
Commonly known as: MOBIC
About This Medication
Instructions: Take 7.5 mg by mouth daily.
Documented by XXXXXXX XXXX
Brief Answer:
Its orthostatic hypotension
Detailed Answer:
Hello,
It's an orthostatic hypotension. This occurs due to disturbances in autonomic nervous system due to age. I assume your thyroid, blood sugars are normal. Also, get Vit b12 levels tested. And yes you are right, syncope may not a appropriate term, dizziness or presyncope would be better.
For pots there has to sustained heart rate increase of greater than 30 beats per minute or an increase to 120 beats per minute or greater and for vasovagal, usually heart rate decreases along with low bp.
In treatment, you continue all physical manoeuvres, plenty of fluids. If not adequately responding to fludrocortisone, dose can be increased gradually to 0.2 then 0.3 mg once a day. However, blood pressure should be monitored and potassium levels should be checked within a week after dose change.
If still not helpful then another medicine like tab Midodrine Oral, 10 mg 3 times daily during daytime hours ( every 3-4 hrs ) should be started. So you discuss these issues with local doctor.
Hope this helps you and get back if you have any doubts.
Its orthostatic hypotension
Detailed Answer:
Hello,
It's an orthostatic hypotension. This occurs due to disturbances in autonomic nervous system due to age. I assume your thyroid, blood sugars are normal. Also, get Vit b12 levels tested. And yes you are right, syncope may not a appropriate term, dizziness or presyncope would be better.
For pots there has to sustained heart rate increase of greater than 30 beats per minute or an increase to 120 beats per minute or greater and for vasovagal, usually heart rate decreases along with low bp.
In treatment, you continue all physical manoeuvres, plenty of fluids. If not adequately responding to fludrocortisone, dose can be increased gradually to 0.2 then 0.3 mg once a day. However, blood pressure should be monitored and potassium levels should be checked within a week after dose change.
If still not helpful then another medicine like tab Midodrine Oral, 10 mg 3 times daily during daytime hours ( every 3-4 hrs ) should be started. So you discuss these issues with local doctor.
Hope this helps you and get back if you have any doubts.
Above answer was peer-reviewed by :
Dr. Raju A.T
Brief Answer:
Yes
Detailed Answer:
Yes, infact it's a drug of choice in orthostatic hypotension.
The basic pathology is same in both vasovagal and orthostatic, in vasovagal there is vascular relaxation leading to relative blood volume deficit coupled with low heart rate, while in orthostatic blood accumulates in lower part of body and body failed to constrict vessels sufficiently to raise bp resulting in relative blood volume deficit. Fludrocortisone increases blood volume and prevent these.
Yes
Detailed Answer:
Yes, infact it's a drug of choice in orthostatic hypotension.
The basic pathology is same in both vasovagal and orthostatic, in vasovagal there is vascular relaxation leading to relative blood volume deficit coupled with low heart rate, while in orthostatic blood accumulates in lower part of body and body failed to constrict vessels sufficiently to raise bp resulting in relative blood volume deficit. Fludrocortisone increases blood volume and prevent these.
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Answered by
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