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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Symptoms of reduced cerebral perfusion upon assuming an upright position—dizziness to frank syncope

  • Marked fall in blood pressure within 3 minutes of standing (> 20 mm Hg systolic or > 10 mm Hg diastolic)

GENERAL CONSIDERATIONS

  • This disorder may be symptomatic or asymptomatic

  • Symptoms are worse in the morning, after meals, and after exercise

  • Usual causes include volume depletion (usually secondary to diuretics), vasodilators, and neurogenic causes such as primary and secondary causes of autonomic failure

  • Elderly population is most commonly affected owing to reduced baroreceptor sensitivity, impaired thirst mechanism, and reduced cerebral blood flow

  • Parkinson’s disease and multiple-system atrophy (Shy-Drager syndrome) may cause orthostatic hypotension

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Lightheadedness

  • Dizziness

  • Blurred vision

  • Weakness

  • Palpitation

  • Tremulousness

  • Syncope

PHYSICAL EXAM FINDINGS

  • Postural drop in blood pressure of > 20 mm Hg systolic or > 10 mm Hg diastolic

  • Features of neurologic disease if present

DIFFERENTIAL DIAGNOSIS/CAUSES

  • Fluid loss, anemia, dehydration

  • Primary autonomic dysfunction: Shy-Drager syndrome

  • Secondary dysautonomia:

    • – Parkinson’s disease

    • – Diabetes mellitus

    • – Amyloidosis

    • – Human immunodeficiency virus infection

    • – Multiple sclerosis

  • Vasoactive medications:

    • – Antihypertensive agents

    • – Ethanol

    • – Psychoactive drugs

  • Advanced age: akinetic falling spells of the aged

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, basic metabolic panel

ELECTROCARDIOGRAPHY

  • ECG to screen for underlying conduction disease

IMAGING STUDIES

  • None required for diagnosis

DIAGNOSTIC PROCEDURES

  • Autonomic nervous system studies may be indicated

TREATMENT

CARDIOLOGY REFERRAL

  • Seldom required unless initial management is not successful or diagnosis is in question

HOSPITALIZATION CRITERIA

  • Syncope secondary to profound volume depletion

  • Recurrent syncope

  • Trauma secondary to syncope

MEDICATIONS

  • Treat underlying cause if possible

  • Wear elastic stockings

  • Maintain adequate salt and water intake

  • Administer fludrocortisone 0.1–1.0 mg PO daily

  • Give alpha1-adrenergic agonists, eg, midodrine 10 mg 3 times PO daily

THERAPEUTIC PROCEDURES

  • None required

MONITORING

  • Orthostatic blood pressure monitoring after initiation of treatment

DIET AND ACTIVITY

  • Liberal salt intake to maintain euvolemia

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • After initiation of therapy

FOLLOW-UP

  • Initially 2 weeks; after that 3 months, depending on response

COMPLICATIONS

  • Trauma secondary to syncope

PROGNOSIS

  • Prognosis depends on precipitating cause

  • Multisystem atrophy carries the worst prognosis

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