Non-pharmacologic management of orthostatic hypotension

doi:10.1016/j.autneu.2020.102732

Autonomic Neuroscience

Volume 229, December 2020, 102732

https://doi.org/10.1016/j.autneu.2020.102732 Get rights and content

Abstract

Orthostatic hypotension (OH), a debilitating disorder characterized by a drop in blood pressure when in the upright position, may be treated through several pharmacologic and lifestyle modifications. The treatment is aimed at decreasing the symptoms, mainly the falls, increase the standing time, and improve the activities of daily life. A recent expert consensus outlined the management of orthostatic hypotension and included 4 sequential steps: 1) review medications and modify or remove those that may aggravate or cause OH; 2) non-pharmacologic measures; 3) pharmacologic measures and 4) treatment combinations. The aim of this manuscript is to review the non-pharmacological approach. In milder cases, this approach may suffice, but with more severe symptoms, such as falls, syncope or near-syncope, a pharmacological strategy is simultaneously employed. Furthermore, most non-pharmacological measures are combined. The non-pharmacological approach is aimed at optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis.

Section snippets

Meals

Food ingestion produces blood pooling in the splanchnic bed, normally compensated by a sympathetic vasoconstriction. In patients with neurogenic OH and the elderly, this mechanism is decreased, producing a drop in the blood pressure about 2 h after a meal (Palma and Kaufmann, 2020). In the elderly, the mean arterial pressure declines by 17 +/−2 mmHg after a meal (Jansen et al., 1995). This decrease may be even greater in patients with associated diseases such as hypertension. Of course, an even

Fluid and sodium intake

Daily fluid intake recommended in the management of OH should be in the range of 2–2.5 L per day with a diet rich in salt in the range of 10–20 g/day (Ali et al., 2018). Increasing salt and water intake has multiple purposes. First, the combination of salt and water expansion increases total blood intravascular volume (Wieling et al., 2002) and thereby increases orthostatic tolerance. For this reason, the supplementation should occur in the morning and early afternoon and is not needed prior to

Counter maneuvers

Several counter maneuvers increase standing blood pressure. Bending forward, squatting and abdominal compression increases the blood pressure as well as the cardiac output in patients with familial dysautonomia (Tutaj et al., 2006). Leg crossing increases the blood pressure and stroke volume in subjects with orthostatic hypotension by 13+/−13 mmHg, while it does not produce any effect in healthy individuals (Ten Harkel et al., 1994). Tiptoeing does not increase the blood pressure in patients

Patient education, conclusions and practical tips

As with any chronic disorder, patient education plays a major role in helping the patient and their caregivers understand why specific recommendations were made, and how to modify them based on changing circumstances. About half of the patients with profound OH (a drop of nearly 100 mmHg from lying to standing) will not have typically recognizable symptoms (Arbogast et al., 2009). Since detecting symptoms of a blood pressure drop is critical to preventing falls (Lipsitz, 2017), especially in

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Non-pharmacologic management of orthostatic hypotension☆

Abstract

Section snippets

Meals

Fluid and sodium intake

Counter maneuvers

Patient education, conclusions and practical tips

Am. J. Med.

Can J Cardiol

J. Nutr.

J. Neurol. Sci.

J. Am. Coll. Cardiol.

Efficacy of orthostatic self-training in medically refractory neurocardiogenic syncope

Clin. Exp. Hypertens.

Management of Orthostatic Hypotension: a literature review

Cureus

Efficacy of compression of different capacitance beds in the amelioration of orthostatic hypotension

Clin. Auton. Res.

The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension

J. Neurol.

Postprandial hypotension: epidemiology, pathophysiology, and clinical management

Ann. Intern. Med.

Postprandial hypotension in elderly patients with unexplained syncope

Arch. Intern. Med.

Acute effect of water on blood pressure. What do we know?

Clin. Auton. Res.

The pressor response to water drinking in humans: a sympathetic reflex?

Circulation