#187 Orthostatic Hypotension Part 1: Gray Matters Segment

[SPEAKER_01]: This podcast is for educational and informational purposes only, and does not constitute formal medical advice, clinical guidance, or institutional policy.

[SPEAKER_01]: The views expressed are those of the hosting guests and may not reflect those of any official policies or affiliated organizations. [SPEAKER_01]: Always verify information, consult appropriate resources, and apply your own clinical judgment before caring for patients. [SPEAKER_01]: Welcome to Gray Matters, where we unpack how medical management is rarely black or white. [SPEAKER_04]: And go on deep diets along the way. [SPEAKER_01]: I'm Dr. Nick Philano.

[SPEAKER_04]: And I'm Dr. Schreit Shrevetty. [SPEAKER_01]: So Shreit, it's been a while. [SPEAKER_01]: I'm looking forward to jumping back into the fog of uncertainty with you. [SPEAKER_04]: Ah, the fog of uncertainty. [SPEAKER_04]: Sounds really dreadful, but I do think it's easier to cut through fog with some help and some friends. [SPEAKER_01]: So, I had this patient on the inpatient ward recently.

[SPEAKER_01]: He's 72, he has a history of hypertension and diabetes, and he comes in with syncopy. [SPEAKER_01]: Turns out, he had severe urinary retention. [SPEAKER_01]: I mean, they placed a catheter in the ED and over a leader of urn came out. [SPEAKER_04]: A leader, gosh, I basically so uncomfortable to even think about.

[SPEAKER_01]: I know it's one of those things you can just feel, but to figure out why he had sphere urinary attention, you know, we got an MRI that showed that his prostate wasn't too big and there was no chord compression, but eventually we did find out that his hemoglobin A1C was 12.5% so we started insulin. [SPEAKER_04]: I was still thinking about that urinary attention. [SPEAKER_04]: I bet he had a pretty nonly AKI from that.

[SPEAKER_01]: But thankfully, the AKI did resolve with the catheter. [SPEAKER_01]: He did have some post-substructive diarrhea recess, you know, he got a little light headed since he was peeing a ton, but we gave him fluids and eventually his polyureka resolved. [SPEAKER_04]: What happened next? [SPEAKER_01]: So here's the thing, his polyurethalves, but his lightheadedness did not resolve. [SPEAKER_01]: I had been giving him a lot of fluids, he had been net positive for a few days now.

[SPEAKER_01]: You know, like I said, his sugars were looking better, so I was like, there's no way this patient can still be dehydrated. [SPEAKER_01]: And then I realized, I'm facing my old nemesis. [SPEAKER_04]: Oh no, don't say it. [SPEAKER_04]: The biggest discharge blocker of them all. [SPEAKER_01]: Hmm, afraid so, orthostatic hypotension. [SPEAKER_04]: Yeah, uh, sympathy.

[SPEAKER_04]: And though I will say Nick, I'm glad we're talking about this because I feel like our patients are so complex in the hospital and often slips my radar until I got a message from a nurse, like the day before we're just trying out the space and almost, you know, passed out when they stood up or their well-pressure was this when they stood up. [SPEAKER_01]: Yeah, I mean, if it's not on the problem list, we sometimes forget about it, but it's surprisingly common.

[SPEAKER_01]: I found that one in five patients are over the age of 60 actually deal with over the set of hypertension.

[SPEAKER_01]: In some studies actually documented it in half of nursing home residents. [SPEAKER_04]: It's humbling to even think that we might even catch more people if we actually diagnosed it correctly. [SPEAKER_04]: So why don't we start there? [SPEAKER_01]: Yes, that is exactly where I want to take us for our first deep dive. [SPEAKER_01]: Because I learned that it's a lot more than just having someone stand up and check their blood pressure.

[SPEAKER_04]: Okay, I think we've all learned that orthicetic hypertension is a consequence of changing position, right? [SPEAKER_04]: We stand up, blood pulls in the leg, and the gut, and so venus return drops, and so as a cardiac output. [SPEAKER_04]: And then normally our nervous system detects that and ramps up our sympathetic tone and we're fine. [SPEAKER_04]: We just go all about our day.

[SPEAKER_04]: But if our nervous system or our heart can't respond normally, then the blood pressure stays low, our cerebral profusion drops, and then we pass out or just feel awful. [SPEAKER_04]: and we're looking for that drop in the blood pressure when standing to make the diagnosis.

[SPEAKER_01]: Exactly, and we're precisely the official diagnosis would be a drop in cystallic blood pressure by 20 millimetres of mercury or a drop in dyesolic blood pressure by 10 millimetres of mercury when standing. [SPEAKER_04]: I care as well. [SPEAKER_04]: Where are we getting those numbers from? [SPEAKER_04]: Like why? [SPEAKER_04]: Is it 20 millimetres of mercury in 10 millimetres of mercury? [SPEAKER_04]: Two those numbers have any real significance.

[SPEAKER_00]: ultimately what's important is what level of blood pressure change results in bad outcomes. [SPEAKER_00]: So studies have looked at that. [SPEAKER_00]: And the reason that we come up with a number like 20 millimeters of systolic pressure is because they drop of 20 or more millimeters pressure in systolic pressure is associated with bad outcomes.

[SPEAKER_00]: Such a dizziness falls, syncopy. [SPEAKER_00]: I am Lou Lipsitz, a geriatrician. [SPEAKER_00]: I am currently a professor of medicine at Harvard Medical School and director of the Marcus Institute for Aging Research at Hebrews in your life. [SPEAKER_00]: Syncopy falls myocardial infarction, cognitive impairment. [SPEAKER_00]: So that's why we use those parameters as sort of guidelines as to what might be significant.

[SPEAKER_04]: Wow, I did not think about how orthostatic hypertension could be related to heart attacks, right? [SPEAKER_04]: But now, I think about it, it makes sense that the coronary's filled during diastole and that diastole flood pressure can get pretty low in orthostatic hypertension. [SPEAKER_01]: Yeah, it sure can. [SPEAKER_01]: I mean, some people even consider orthosatocipids mentioned an independent risk factor for cardiovascular disease.

[SPEAKER_01]: You know, I saw studies where it was associated with mortality and cognitive decline. [SPEAKER_01]: But I mean, what's the takeaway here, you know, catching this disease is important. [SPEAKER_01]: And the measurements unfortunately aren't always consistent. [SPEAKER_01]: I mean, blood pressure measurements have actually been shown to be way more variable than we'd like to think.

[SPEAKER_01]: sometimes by 10 to 20 millimeters of mercury between measurements, and that could even worse at higher blood pressures, which is why diagnosis is even trickier in patients with hypertension. [SPEAKER_04]: in a minute, variations of like 10 to 20 millimeters per work year. [SPEAKER_04]: That's basically the difference between calling something worth a ton of type potential. [SPEAKER_04]: Like literally like those are the numbers in the definition, right?

[SPEAKER_04]: I think that definitely makes you feel more compelled to know then how exactly who should measure that blood pressure as accurately as possible. [SPEAKER_04]: I think it's make sure we have the right size cuff and then second making sure that arm is supported and at the heart level. [SPEAKER_01]: Yeah, and I didn't know this, but actually a third thing is to have them lay flat for about five minutes to allow the blood pressure to stabilize.

[SPEAKER_01]: And most guidelines actually suggest checking the blood pressure at least twice to get a good baseline to compare our standing vital signs too. [SPEAKER_01]: I mean, you know, if you can find time to do that in the hospital. [SPEAKER_04]: Wait, Nick, I have some scenes and technicians and nurses just compare blood pressures from sitting to standing. [SPEAKER_04]: Is that right?

[SPEAKER_00]: they're going to equilibrate when they're sitting, and you're not going to really know what happens under the maximal stress of supine to stand it, which is what most people do when they think.

[SPEAKER_01]: So yeah, some advocates skipping sitting since blood pressure management is going from laying to standing actually have a higher correlation with falls and symptoms, and also it's more realistic with how people get out of bed. [SPEAKER_02]: have to check the blood pressure after the patient is going down for at least five minutes.

[SPEAKER_02]: And then you ask a patient to stand up and you try to collect the blood pressure as one, three, five, ten minutes if the patient tolerates it. [SPEAKER_02]: And you also have to measure the hard rate. [SPEAKER_01]: That's Dr. Cindy Shabal, our second consultant. [SPEAKER_02]: My name is Cindy Shibal and I am a tenure professor of medicine at Vanneville University Medical Center and they associate director of the autonomic dysfunction center.

[SPEAKER_04]: Wait a minute, let me just make sure I heard that correctly, Neng. [SPEAKER_04]: They want us to check a blood pressure after standing at 1 minute, 3 minutes, 5 minutes and 10 minutes. [SPEAKER_01]: Yeah, I know, it's going to be tricky to get all these different data points in a busy hospital or clinic setting.

[SPEAKER_01]: But the point here is that if we only check the blood pressure one minute after standing, we may miss people who get symptoms of two minutes or three minutes, you know, it's not that uncommon. [SPEAKER_04]: Yeah, fair. [SPEAKER_04]: I mean, I guess waiting longer will increase the sensitivity in patients who we have a higher access suspicion for. [SPEAKER_01]: Yeah, patients who have early neurogenic disease actually tend to have a delay in their symptoms with standing.

[SPEAKER_04]: that's interesting. [SPEAKER_04]: That's good to know. [SPEAKER_04]: So this is all about how to take a blood pressure in an ideal world where you have time and the patient's is also patient with it. [SPEAKER_04]: But I'm curious, does it matter when we check that orthotic blood pressure? [SPEAKER_04]: I mean, most of us just order AM orthotic vital signs, right? [SPEAKER_04]: But is that the right thing to do?

[SPEAKER_00]: What you want to do is put them through the exact same situation in which they faint did it occur after meal to occur an hour after taking a medicine to occur while standing up in the first thing in the morning when they're dehydrated. [SPEAKER_00]: So first part of the answer is test them under the exact same circumstances in which the event whatever it is occurred. [SPEAKER_01]: So you can time your orthostatic fiddle signs around the triggers for the patient's symptoms.

[SPEAKER_01]: Like, were they eating lunch when they stood up and fell? [SPEAKER_01]: Did they get lightheaded after walking around doing like chores? [SPEAKER_01]: If you don't have those triggers, the early morning before medications is a good place to start. [SPEAKER_02]: When course, not to just rely on one measurement, but try to do multiple measurements, particularly in the morning. [SPEAKER_02]: Right?

[SPEAKER_02]: And before the patient takes the medication, because that's the period of time where patients are very, very symptomatic. [SPEAKER_02]: And it's more reliable, because blood pressure in these patients has changed dramatically throughout the day. [SPEAKER_04]: Okay. [SPEAKER_04]: Got it. [SPEAKER_04]: So what did you for your patient who had that severe urinary obstruction now status was a catheter? [SPEAKER_04]: Has this post-obstructure diariesis?

[SPEAKER_04]: That's now resolved, but it's still light-headed and useless backtasked or the cytokine potential. [SPEAKER_01]: So he didn't have any clear triggers, so we just tried measuring his orthostatic vital signs first thing in the morning. [SPEAKER_01]: We got a good cuff. [SPEAKER_01]: We measured his blood pressure twice while laying down, likely we could find a time, and then we stood him right up.

[SPEAKER_01]: He could only stand for about three minutes before symptoms set in, but if you compare his systolic blood pressure were laying down to the blood pressure when standing at one and three minutes and went from 140 to 80 to 75 points. [SPEAKER_01]: So it definitely dropped, and while that happened, [SPEAKER_04]: Wow, Nick. [SPEAKER_04]: That's the song, but pressure dropped to 75. [SPEAKER_04]: Ugh, not good. [SPEAKER_04]: You know, you also reminded me about checking the heart rate.

[SPEAKER_04]: I mean, I remember somewhere along the way learning something about an increase in heart rate. [SPEAKER_04]: Like 30, your 20 can signal orthosatic hypertension. [SPEAKER_01]: Yeah, I'm glad you brought that up. [SPEAKER_01]: You know, I thought the same thing, but yeah, I found out we really just use blood pressure to diagnose orthosatic hypertension.

[SPEAKER_04]: Okay, so if we don't need heart rate for the diagnosis, why are we measuring it? [SPEAKER_01]: So what I found out is that we want to see if the heart rate is doing what we expected to do. [SPEAKER_01]: Basically, is it going up by enough? [SPEAKER_01]: Because if it doesn't, it could mean that there's something wrong with the normal reflex arc to standing, meaning there could be some kind of neurogenic process driving the orthositic hypertension.

[SPEAKER_02]: We kind of tested these new index, so we take the blood pressure supine and is standing at one minute, as well as the heart rate. [SPEAKER_02]: So you calculate the difference in terms of, you know, how much the heart rate goes up from the supine to the upper right posture at one minute. [SPEAKER_02]: and how low the blood pressure drops. [SPEAKER_02]: And then you have this delta, delta, delta, the heart rate divided by the delta of the systolic blood pressure.

[SPEAKER_02]: And if this index is less than 0.5, then there is much, I mean, high-level that this is probably an aeronomic neuropathy, compared to blood volume depletion or this other factors that we just discussed. [SPEAKER_01]: and we will link to the ratio of the change in heart rate to the change in systolic blood pressure at one minute in our show notes.

[SPEAKER_01]: But another way to put it is that if the autonomic reflexes are intact, that is if they're not being affected by neurogenic disease or medication like a beta blocker, then for every two points that your systolic blood pressure drops when you stand, your heart rate should go up by one. [SPEAKER_01]: So the change in heart rate over the change in systolic blood pressure should be at least 0.5 for higher.

[SPEAKER_04]: Yeah, and so if you do see that change being greater than 0.5, then work good and on an Navigneropathy is less likely on the table. [SPEAKER_01]: Yep, if you see that the change in heart rate over the change in systolic blood pressure and standing is over 1.5, aka you're getting that heart rate response of at least 1 for every 2 point drop in systolic blood pressure, that's pretty suggestive of a non-nerogenic cause of orthostatic hypertension.

[SPEAKER_01]: In fact, it's 91% sensitive and 88% specific. [SPEAKER_04]: nice. [SPEAKER_04]: This is all great learning. [SPEAKER_04]: Let's summarize our best practices we learned on or the static hypotension and making that diagnosis. [SPEAKER_04]: I think one we want to make sure we have good size cuff. [SPEAKER_04]: If we can try to have a patient lace you pine really spive minutes, get a couple base line reads and heart rate reads if we can.

[SPEAKER_04]: have them stand or right up and then document the blood pressure and heart rate and symptoms at one minute three minutes and then longer if we really want to increase the sensitivity.

[SPEAKER_04]: We want to make sure that it's not neurogenic and we're going to look at the heart rate response and see if its blood hit or not and then it could be helpful to do all of this around the seed time that patient initially fell or was throwing symptoms or if not just check it in the morning each day to standardize our readings. [SPEAKER_04]: Okay, Nick, you said your patient's testosterone blood pressure dropped from 140 to 80 at minute one.

[SPEAKER_04]: That's a change of 60 millimeters per mercury. [SPEAKER_04]: And so you'd expect that hurry to go up by at least 0.5 or half, so at least 30 beats per minute. [SPEAKER_04]: But your patient's hurry just went from 70 to 85. [SPEAKER_04]: Nick, what do you make of that?

[SPEAKER_01]: Yeah, I mean, I went back and I found that he did have some signs that he might have lost some fine touch and proprioception in the toes, so I was thinking that maybe his uncontrolled diabetes was causing peripheral autonomic dysfunction, and maybe that contributed to his urinary attention in the first place, and now is contributing to his orthostatic hypertension.

[SPEAKER_04]: Yeah, real quick, Nick, we thorough on the term neurogenic causes often, but clear is kind, why don't we talk a little bit more about what exactly you put in that bucket versus other causes? [SPEAKER_01]: Absolutely. [SPEAKER_01]: I mean, that's a great question because the causes of orthostatic hypertension could really be its own big topic and episode. [SPEAKER_01]: So let's keep things really simple and just think about two major buckets.

[SPEAKER_01]: The first bucket is going to be your neurogenic causes. [SPEAKER_01]: Anything that impairs the normal baro receptor reflexive sensing a low blood pressure and then doubling neuroprinter from levels in response. [SPEAKER_01]: So this could be neurodegenerative diseases, things like Parkinson's disease or multi-susence atrophy, [SPEAKER_01]: or it could be neuropathes, things like diabetes or amolidosis. [SPEAKER_01]: The other bucket are the non-neurogenic causes.

[SPEAKER_01]: These are things that are going to impact being this return, like dehydration, or things that will impact cardiac output. [SPEAKER_01]: You know, things like heart disease or a vascular disease. [SPEAKER_01]: I did put in the show notes a deeper breakdown of causes for those interested, but just remember that a neurology referral can be helpful since some of these diseases can actually fall across both buckets. [SPEAKER_04]: uh, interesting.

[SPEAKER_04]: I'm glad we're talking about narrow versus not narrow because I think they do have big implications in terms of treatment goals. [SPEAKER_04]: And speaking of which, you know, I feel like most people put birth treatment goal, like free check am or set up blood pressure and discharge when not worth static.

[SPEAKER_01]: Yeah, I mean, I like making numbers look nice as much as the next internal medicine doctor, but that can be really hard for patients with or with a cytokine potential. [SPEAKER_01]: And these patients aren't all the same, so what are our treatment goals and how does that depend on the specific patient we're treating? [SPEAKER_01]: So I always thought that our treatment goal was going to be just making the standing blood pressure better.

[SPEAKER_01]: I mean, that makes sense, right? [SPEAKER_01]: But this one circulation review article flip my whole approach to treating orthosatic hypertension. [SPEAKER_01]: It's said that the goal is improvement in symptoms and functionality, rather than correction of the orthosatic hypertension, and recommendations from other societies are in line with this.

[SPEAKER_04]: Okay, so improving symptoms and functionality, that feels like a realistic all-nick and probably a lot more patient-friendly, but it's also not very specific. [SPEAKER_04]: How do we actually do this? [SPEAKER_01]: I mean, first off, yeah, we're not focusing on a particular number, but there are two summit nuance caveats to that. [SPEAKER_01]: The first is, we do want to try keeping the standing blood pressure out of the danger zone.

[SPEAKER_04]: But what exactly isn't a blood pressure target that's not a danger zone for patients? [SPEAKER_04]: I mean, your patients blood pressure dropped like 75 milligrams of mercury at one point, right? [SPEAKER_04]: Like, it's pretty low. [SPEAKER_01]: Yeah, I agree that is pretty low, but what's out of the danger zone can get a little bit gray.

[SPEAKER_01]: I mean, the brain adjusts its blood flow separate from the mean arterial pressure, aka the map, and it does that to keep the brain fed and happy at different blood pressures. [SPEAKER_01]: But everyone's brain does this differently. [SPEAKER_01]: So how low can a patient's map get before it affects the cerebral blood flow is hard to say, but our consultants did have some guidance here.

[SPEAKER_00]: I will also try to just keep that systolic above 100, because that's really, I think, a critical, in easy, on easily observed value that is sort of a critical point between profusion and not. [SPEAKER_01]: So for many patients, aiming for a standing, systolic blood pressure goal that least 100 is a reasonable goal to make sure that the brain and the coronaries are profusing, and you know that they're able to do their daily activities.

[SPEAKER_01]: The other caveat that we wanted to talk about here are patients with true severe neurogenic disease. [SPEAKER_02]: Now, if the patient has a autonomic failure, they're always going to have auto-study hypotension. [SPEAKER_02]: I mean, you're not going to cure that, because the problem with this patient is that cardiovascular autonomic reflexes are impaired.

[SPEAKER_00]: And I don't care so much whether it's a 90-millimeter systolic or not, as long as they're able to do their activities. [SPEAKER_00]: And because I know they're risk-effically. [SPEAKER_00]: I mean, I already know that. [SPEAKER_00]: The question is, how long can I have them stand up? [SPEAKER_04]: Yeah, I've definitely had neurology consults have different thresholds for patients with severe neurogenic or cytokine potential.

[SPEAKER_04]: I think it's just a different group of patients where it gets even more gray and the number cut-offs that are dangerous for them is just a different ballgame. [SPEAKER_01]: Blood pressure goals can be so hard, especially in this population. [SPEAKER_01]: So I want to take a step back towards our main goal of reducing or stopping any symptoms that affect functionality.

[SPEAKER_01]: You know, when I think about symptoms that come with the orthostatic hypertension, I really like using this term orthostatic intolerant symptoms to remind myself to not just anchor on lightheadedness.

[SPEAKER_01]: That reminds me to think of any symptom that can come with standing. [SPEAKER_03]: Sometimes patients won't describe it necessarily as lightheadedness or dizziness, they might just say they feel weak or they feel a little unsteady or even if you kind of dive into it like you watch their face. [SPEAKER_03]: It looks like you're not feeling well right now. [SPEAKER_03]: So there's quite a bit of me looking right out them when they're doing this to make sure I'm not seeing anything.

[SPEAKER_01]: That's our third consultant, physical therapist Sharon Gorman. [SPEAKER_03]: So my name is Sharon Gorman. [SPEAKER_03]: I am a licensed physical therapist. [SPEAKER_03]: I've been a physical therapist for more than 20 years. [SPEAKER_01]: So you can get vision issues. [SPEAKER_01]: You can get chest pain from poor coronary flow. [SPEAKER_01]: One interesting symptom is called coat hanger pain that comes from decreased blood flow to the trapezius.

[SPEAKER_01]: Symptoms can also be subtle. [SPEAKER_01]: Like I wonder how many times I've written asymptomatic orthostatic hypertension as a diagnosis. [SPEAKER_01]: When my patient actually did have something, like maybe mild confusion when they stood up. [SPEAKER_04]: I think like the other flip side of all this neck is like what if we have a patient who doesn't have truly any warning symptoms right they just fell before they could respond.

[SPEAKER_00]: Most people will be able to experience symptoms when they have a reduction in blood flow, but not everyone, particularly if they're older and have dementia or other conditions may not be able to experience that. [SPEAKER_01]: Yeah, that's a super high risk group. [SPEAKER_01]: I mean, patients who have severe disorder and omega dementia, where they may not be able to sense their orthostasis before falling, if it really worries me.

[SPEAKER_04]: Yeah, and I think like in some sense, like falling with no warning signs, people just assume, like, oh, maybe it's cardgenic, and that's what they only worry about, but I think the other thing to keep in mind on the differential is maybe they have really bad or it's static hypotension.

[SPEAKER_01]: Yeah, I feel like sometimes when we think that the fall was caused by orthostatic hypertension were almost reassured, but it could still be really dangerous, especially in these patients within the warning. [SPEAKER_04]: Yeah, definitely.

[SPEAKER_04]: The other patient scenario to think about is person we see in clinic who has actually positive orthostatic vitals, but they're doing fine, they have no symptoms, they haven't fell, they're targeting it, this drop in blood pressure just fine. [SPEAKER_04]: So what do we do about that?

[SPEAKER_01]: Yeah, there are some patients who can physically tolerate a slightly lower blood pressure, you know, like their cerebral blood flow can adapt, but as much as I hate to find a problem with someone being fine, even if they're truly asymptomatic right now, study show that asymptomatic orthostatic hypertension will often progress. [SPEAKER_01]: In one study of older adults, the risk of unexplained falls doubled in these patients after 60 years. [SPEAKER_04]: Oh, man.

[SPEAKER_04]: I just want to point out new ones here. [SPEAKER_04]: You know, we said earlier that our treatment goal is symptoms and functionality, but at the same time, it seems like we just can't ignore that low blood pressure number when they stand. [SPEAKER_04]: I think it seems like consistently throughout this episode. [SPEAKER_04]: It's shown as it does carry a poor, prognostic sign for bad outcomes to come later. [SPEAKER_01]: definitely.

[SPEAKER_01]: To summarize the bigger point here, our treatment goal should be to focus on functionality and symptoms. [SPEAKER_01]: And on the point of symptoms, we really want to investigate if there are any symptoms at all of orthosatic intolerance when the patient stands up. [SPEAKER_01]: Science of poor organ provision like chest pain, vision or mental status changes, or even neck pain.

[SPEAKER_04]: Yeah, and while we don't want to focus on the number entirely in terms of our treatment goal, we do want to make sure that standing blood pressure is out of that danger zone, so for most people, it's going to be trying to get them up to at least a solid blood pressure of 90s to 100s when they stand, and of course it's going to be challenging and the thresholds are so different, and treatment goals are so different when it comes to severe, just not to know me yet, but the near-genetic patients neurology will just have some different individualized treatment goals.

[SPEAKER_04]: Okay, so let's try to apply some of these treatment goals to your patient when you're treating this patient. [SPEAKER_04]: What are you hoping to achieve? [SPEAKER_01]: Definitely, that's a great question. [SPEAKER_01]: So when he stood up, he did report lightheadedness as well as feeling like his thoughts were kind of foggy. [SPEAKER_01]: So I thought, okay, that's what I want to get better with treatment.

[SPEAKER_01]: And hopefully get a societal blood pressure to the 90s or hundreds while we do it? [SPEAKER_04]: Yeah, man, I hope this isn't [SPEAKER_01]: Yeah, I know. [SPEAKER_01]: I mean, medications are an important, important avenue. [SPEAKER_01]: But I love you're driving at the question of how we can intervene with out medications right now. [SPEAKER_01]: And this let me down a road with a lot of different pit stops.

[SPEAKER_01]: You know, I learn the different people, need different kinds of fuel. [SPEAKER_04]: Oh man, what a clunky and now I'll do it. [SPEAKER_04]: Do appreciate some love, buddy. [SPEAKER_01]: So let's open the hood and how to prevent or treat orthostatic hypertension in the hospital without medications. [SPEAKER_04]: Okay, yes, I love thinking about non-farmic lateral treatment.

[SPEAKER_04]: I don't know why, but it just makes me feel like such a good medicine doctor, not using actual medicines. [SPEAKER_01]: I totally get that. [SPEAKER_01]: That circulation paper recommended four big non-farmic logic interventions for everyone with orthosatica hypertension, regardless of symptoms. [SPEAKER_01]: And that starts with the oldest medicine known to man. [SPEAKER_01]: Your body's staying upright depends on your body continuing to move.

[SPEAKER_01]: Otherwise, gravity wins. [SPEAKER_00]: Interestingly, if you take the most healthy, fit astronaut and set him up to space for 24 hours, when they get back down on Earth, they can't stand. [SPEAKER_00]: So, it's not unusual that our older patients admitted to the hospital. [SPEAKER_00]: I've worked this telekite potential when they tried to stand up after a prolonged bed rest.

[SPEAKER_01]: Yes, so once study the elderly impatience found that daily bed rest of at least nine hours more than doubled morning orthostatic hypertension. [SPEAKER_01]: When you rest, you retain less fluids, you aren't working your leg muscle pump, and those bearer receptors that help you stay vertical actually get less sensitive with time, and then, low and behold, orthostatic hypertension develops.

[SPEAKER_03]: A lot of patients think they can't get up because they have lines and tubes on them. [SPEAKER_03]: There was actually great study out of Australia with really healthy people who had no restrictions when they were in the hospital. [SPEAKER_03]: And the number one reason they said they didn't get up was they had a fully catheter, which is like the easiest thing to take with you and walk.

[SPEAKER_03]: But they thought because they had that and it hangs on the bed, I can't go anywhere. [SPEAKER_03]: and just such the big person who pushes like everyone who can do whatever they can to encourage mobility. [SPEAKER_03]: And even if that's you is the physician asking the patient when you come in the room, did you get up today? [SPEAKER_03]: How often have you gotten up today? [SPEAKER_03]: Why are you getting up? [SPEAKER_03]: Oh, what's stopping you from getting up?

[SPEAKER_03]: How can we help you get up more? [SPEAKER_03]: Even if you just ask those questions, that's giving the message to the patient that they need to move around. [SPEAKER_01]: Yeah, but one thing is that my patient already has orthosetic hypertension. [SPEAKER_01]: I mean, I still want to encourage exercise, but I can't exactly tell my patient who almost passes out when they stand up to go walk laps around the unit.

[SPEAKER_01]: I mean, I was honestly kind of worrying that maybe it's too late to promote mobility. [SPEAKER_01]: But, you know, our experts assured me that we can still get these patients moving, even if that doesn't mean standing.

[SPEAKER_03]: If I have somebody who I know has a really big problem with orthostasis, I may put the head of the bed up, let them start adjusting to that, do some lower extremity exercises in bed first to try and boost that Venus return get those muscle pumps helping. [SPEAKER_01]: I thought this was super interesting.

[SPEAKER_01]: I talked to Sharon a bit more and she said that for these in bed exercises, she recommends patients to at least five to ten reps in bed like two to three times a day, especially is a warm up to get blood moving before they get up and move. [SPEAKER_00]: And you might want to start with supine bicycle exercises, which are great because you're not standing upright, but you're supine and you're using your leg muscles.

[SPEAKER_00]: There was a nice study a number of years ago that showed that people with severe orthostatic hypertension could lie in bed and take these therabans, you know, these stretchy rubber bands. [SPEAKER_00]: and put them around their feet and extend their feet 10 on one side, 10 on the other side, and then stand up. [SPEAKER_00]: And they actually ameliorated much of the orthostatic hypotension and are able to them to do their activities that they needed to do in the morning.

[SPEAKER_04]: Wow, can we get our patients therapy ends? [SPEAKER_04]: This ends so cool. [SPEAKER_04]: You know, Nick, I've just, I do love giving my patients a homework. [SPEAKER_04]: I do love telling them, like, I want you to do knee bends and arm raises every hour. [SPEAKER_04]: And I'm sure, like, our physical therapy colleagues have, even better exercises like some of the ones they just mentioned, like the semi-supine bicycle movements.

[SPEAKER_04]: Even, like, season lift-offs can be helpful in terms of getting muscle pumping without having them actually stand. [SPEAKER_01]: Okay, so the first non-pharmacologic treatment is to get patients moving. [SPEAKER_01]: The second is that you want to look for anything that's clearly treatable or reversible that contributes to the orthostatic hypertension. [SPEAKER_01]: Think here about dehydration to start.

[SPEAKER_01]: Many patients have poor appetite at baseline as they get older than in the hospital. [SPEAKER_01]: They face long emergency room stays without food or fluids. [SPEAKER_01]: And PO status, restrictive diets, aggressive diariesis. [SPEAKER_01]: I mean, we are kind of pros at dehydration.

[SPEAKER_04]: Yeah, I think we've already touched on some causes, you know, we thought about if dehydrations contributing, if there's some autonogdeous function at play, I think the one we've left out is a really big offender, which is medications. [SPEAKER_01]: Yeah, what caught my eye on my patient's medication list was this is Isisorabide mononitrate and is Lucina Pro. [SPEAKER_02]: So one of the things that we usually do is we look at one medication these patients are taking.

[SPEAKER_02]: Sometimes, you know, you can find hidden agents, like, for example, design, it's a big problem in the south. [SPEAKER_02]: There is an overuse of the medication. [SPEAKER_02]: People don't know that it's similar to cloning, for example. [SPEAKER_02]: Right? [SPEAKER_02]: So you have to stop the medication.

[SPEAKER_02]: When we look at the type of medication that really produce a lot of problems with all the study hypertension, for example, when I bloggers, one of the culprits that are ready, that's an article called culprits, you know, but so the latest, like knife editing, for example, that hand calls all the study hypertension. [SPEAKER_02]: So what we are asking is, don't stop everything, just stop the medications that has been associated with all the study hypertension.

[SPEAKER_01]: So focus on holding or reducing high-risk medications. [SPEAKER_01]: Being dehydrated is a risk for falls, so be careful with loop diuretics. [SPEAKER_01]: I think about anything that will block the adrenergic response to standing. [SPEAKER_01]: Things like beta blockers, alpha blockers, like doxazosin or tantalocin or even tricyclic antidepressants, or alpha-2 agonis, like tysanidine or clonidine.

[SPEAKER_01]: Finally, if your blood vessels dilate as you stand up, you're gonna be a high-risk for falls. [SPEAKER_01]: So primary phase of dilators like nitrates can also be high-risk. [SPEAKER_04]: nice, nice. [SPEAKER_04]: Let me just reiterate that and away my brain can understand. [SPEAKER_04]: So maybe I'll just make it like alphabetical to just chunk it out a little bit more.

[SPEAKER_04]: So big offenders, high risk meds are going to be a alpha blockers like tamps a low sin, alpha 2 agonists like clonidine or tazanidine, beta blockers, nitrates that vasodilate and then tricyclic antidepressants. [SPEAKER_04]: You also said that the acid hybrids are caught your eye, but that's not on the high risk category. [SPEAKER_04]: So maybe I'm guessing the [SPEAKER_01]: Yeah, they're relatively lower-risk.

[SPEAKER_01]: I mean, you may still need to hold them if patients remain worth the static on them, but it may not need to be your first move. [SPEAKER_01]: Check the show notes for a graphic on the relative risk of different anti-hypertensive medications on causing orthosatocytotension. [SPEAKER_01]: But basically, to that effect, we held the patient's isosorbidum on a nitrate, but continued hisocenipro. [SPEAKER_04]: great.

[SPEAKER_04]: I think here's the part where I get stuck in it is a third bucket of non-farm things to try which is compression stockings. [SPEAKER_04]: I think I've ordered compression stockings so many times but I'll download binder so many times and I don't know if it's really doing anything and like more so like is this the right fit for my patient? [SPEAKER_01]: Okay so when we start talking about compression things are gonna get a lot more gray.

[SPEAKER_01]: For instance some clinicians say that you need to compress the entire leg and the abdomen to squeeze blood all the way back to the heart. [SPEAKER_04]: Like a tube-tooth paste? [SPEAKER_01]: Like a tube-tooth paste. [SPEAKER_01]: But talking to Dr. Shabbau, she actually made a good case that abdominal binders could be effective on their own. [SPEAKER_02]: So what we did is we took a lot of graduate students.

[SPEAKER_02]: We put them electrodes all over the body, and then we tilt them. [SPEAKER_02]: And then we tried to estimate where the fluid goes when you are tilt-era. [SPEAKER_02]: The majority of the fluids sequestrate in abdominal area. [SPEAKER_02]: Not in the thighs, not in the calf, and definitely not in the feet. [SPEAKER_02]: It goes really to the abdominal area.

[SPEAKER_02]: We have shown that just using an abdominal band, it's as important as using mildering, when we did a comparison between the mildering and the inflatable abdominal binder. [SPEAKER_04]: Wow, what a great high-dliner, abdominal binders are as good as middream in these like healthy graduate students. [SPEAKER_04]: I love this because we know fluids are clusters in the abdomen and so when you stand up, this is where the money is, right?

[SPEAKER_04]: And I love when the science pans out and if [SPEAKER_02]: So what we usually do is, you know, we encourage our patients to wear any of the commercial abdoming on binary, or the number support, and see if with that, they are able to do to have something that might improve and also adhere to the term. [SPEAKER_02]: And so far, for us, I mean, he's been very useful, because the patient liked the fact that they are able to put it on and pull it out or take it out fast.

[SPEAKER_04]: I love how the focus here is super practical, right, because abdominers are just easier for a patient to use on their own in most of our patients are on their own at home, right? [SPEAKER_04]: Because I feel kind of guilty when we're treating a patient with compression stockings and they need all this help in the hospital when they're seeing it's a whole production to get these compression stockings on and so, like, how are they going to really man just that home?

[SPEAKER_01]: Yeah, but then again, just because abdominal binders can be effective, don't totally discount light compression. [SPEAKER_01]: Remember we said it's gray. [SPEAKER_01]: Our older patients with Venus pulling in their legs aren't the healthy graduate students and doctorship-out study that benefited so much from abdominal binders. [SPEAKER_04]: How do we give helpful instructions for older patients who might need light compression too?

[SPEAKER_00]: If we use compression stockings, bunching them up below, then he actually prevents Venus return rather than promotes Venus return. [SPEAKER_00]: And I've always, it's funny as a younger attending, I will always have. [SPEAKER_00]: They've got to be thigh high, because obviously, we don't want to bunch them up below the knee, but I don't know if nobody could get the thigh high when so I absolutely. [SPEAKER_00]: So I have sort of modified my view.

[SPEAKER_00]: I'd say at least if you can get a knee and try not to bunch them up underneath. [SPEAKER_00]: That's probably the best. [SPEAKER_01]: Okay, this is great advice, but I really didn't know what specifically I'd be asking my patients to go and get. [SPEAKER_01]: So I found out that actually most compression stockings actually list how much pressure they apply on the packaging.

[SPEAKER_01]: Dr. Lipsett suggested looking for ones that provide at least 20 to 30 milligrams of mercury of pressure. [SPEAKER_01]: And if those are too hard to get on, you can also try ones that give at least 15 to 20 milligrams of mercury of pressure. [SPEAKER_01]: So yeah, I mean, this is obviously super situational.

[SPEAKER_01]: In our case, we didn't have fitted thigh high compression stockings for my patient, and the ones that we did give him just get bunching up around the knee, kind of like Dr. Lipsett said, you know, we were worried about blocking Venus return. [SPEAKER_01]: So we just stopped using the compression stockings altogether. [SPEAKER_04]: Mm-hmm. [SPEAKER_04]: So I guess for some people, come back as talking as can work and some like your patient it might not.

[SPEAKER_01]: So for the last thing in the non-pharmacologic toolkit, I want to look at behavioral changes that patients can make. [SPEAKER_01]: And to start, I want to talk about something that really surprised me. [SPEAKER_01]: And that's that the way patients shrink their water can actually help to treat orthosatic hypertension. [SPEAKER_02]: The other thing is drinking water as fast as you can.

[SPEAKER_02]: So a lot of these patients, when they drink sizzling answers of water, as fast as they can, the blood pressure increase in about 30 minutes. [SPEAKER_02]: And it's a very good rescue measure. [SPEAKER_02]: To increase the blood pressure, when you know a patient doesn't have access to the medication, or they are in a place where they cannot sit down or lay down, or because they have symptoms. [SPEAKER_01]: Yeah, this is like really interesting.

[SPEAKER_01]: Rapidly drinking about one water bottle's worth of cool water in three to four minutes is like unexpectedly effective. [SPEAKER_01]: Let me get this in a study of older patients that increased standing systolic blood pressure by an average of 12 millimeters of mercury. [SPEAKER_01]: Another study of those with dysadonomia should it increase neuropinephrine levels in patients with neurogenic disease similar to two to three cups of coffee. [SPEAKER_04]: Wait, checking water did this?

[SPEAKER_01]: Yeah, I know. [SPEAKER_01]: The thought is that this works because water is hypotonic, so don't add anything. [SPEAKER_01]: But having patients drink this bowl of water in the morning or before exercise can actually really help. [SPEAKER_04]: Would a clutch hack if there was a medicine hack?

[SPEAKER_04]: I think the other behavior link they've seen people recommend is like stay hydrated not just you know with that morning chug of cold water but like throughout the day I think people have also been told to eat salt I think Nick you were saying you had an attending who's to tell people like have soy sauce in the morning. [SPEAKER_01]: Right.

[SPEAKER_01]: I mean, for patients that aren't at risk or volume overload, you know, recommending at least two leaders per day of fluids can help. [SPEAKER_01]: So that's definitely something to keep in mind. [SPEAKER_01]: You know, I found out that you need like five to 10 grams of sodium per day to really affect your orthosatic blood pressure. [SPEAKER_04]: Yeah, definitely. [SPEAKER_04]: We saw, you know, we are all constantly worried about the, the deema, the hypertension.

[SPEAKER_04]: I think it has to be right for that patient. [SPEAKER_01]: But I just want to move on to think about things we can recommend that our patients [SPEAKER_02]: So, of course, triggers are a big important part of management, right? [SPEAKER_02]: We as a not-to-take shower, not-to-take a hot pot, because that is a isolation. [SPEAKER_02]: We as an try to limit the amount of caffeine, because that produces the ureases and volume depletion.

[SPEAKER_02]: We ascent to wear abdominal binders that, you know, compress the splanic circulation to prevent the significant drop in blood pressure after you trap blood in the splanic when some of blood vessels. [SPEAKER_02]: And we asked the patient if eating, but he got a large meal reaching carbs, a three-year awarding of the symptoms, because some of these patients have both brand-new hypotation.

[SPEAKER_01]: So, changing the patient to more smaller meals to lower those big carbohydrate pulses can actually really help. [SPEAKER_01]: Also, tell them to try to avoid heat, because remember sweating is a sympathetic activity, and patients with the autonomic dysfunction may not be able to do that to cool themselves off. [SPEAKER_04]: great. [SPEAKER_04]: So what I always summarize, all things in the non-formal glyphical buckets that we talked about.

[SPEAKER_04]: First is really promoting exercise mobility, get those muscles pumping. [SPEAKER_04]: Second is really to assess any treatable causes for orthocetic hypertension, like stopping any of those high risk medications. [SPEAKER_04]: And if orthocetic hypertension, [SPEAKER_04]: persist despite all of this, we can consider a compression like abdominal binders or thigh high compression stockings that don't bunch up behind the knee.

[SPEAKER_04]: And then in terms of behavioral changes, we learned about a really cool trick about having patients chug cold water first thing in the morning as fast as possible and that could help with scent or synthetic hypotension and avoid triggers like heat or high carb meals. [SPEAKER_04]: Alright, stay tuned for our next episode where we're going to learn more about what happened to next patients. [SPEAKER_04]: You know, did these non-pharmacological interventions help?

[SPEAKER_04]: And if so, by how much? [SPEAKER_04]: And did he have to reach for some medications? [SPEAKER_04]: And if so, what was the right approach? [SPEAKER_01]: That's a wrap for today. [SPEAKER_01]: You know as much as we love going through this case, we also love going through other cases. [SPEAKER_01]: So if you have one that you want to bring to us, please email us at hello at coreiampodcast.com.

[SPEAKER_01]: And if you found this episode helpful, please share with your team and colleagues and give it a rating on Apple Podcasts or whatever podcasts have to use. [SPEAKER_01]: It really does help people find us. [SPEAKER_04]: Thank you to our viewers, Dr. Adam Strauss, a Dr. Jason Yoon, and as always, opinions expressed our own and to not represent the opinions of any