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Define Orthostatic intolerance
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
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
What are some Neurological conditions that can cause euvolemic orthostatic hypotension?
- Parkinson's disease
- multisystem failure
- CNS tumor
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?
What physical maneuvers can help prevent falls in an orthostatic hypotension pt.?
- Leg crossing
- isometric hand gripping
- respiratory manuvers pursed lip or sniff
- 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)
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?
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?
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 can be __ -__ mins after postural challenge
True or false Delayed orthostasis is more likely to be associated with vasovagal symptoms
_____ 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
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?
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)
What are some common misdiagnoses of POTS
anxiety disorders, ADHD, depression, somatization, deconditioning
What are some Hyperadrenergic symptoms of POTS
- anxiety, fight of flight hyperactivity, overfocused concentration, mimicking ADHD, Inability to shut down at night or sleeplessness
- Gastrointestinal dysmotility, Raynaud's symptomatology, cutaneous vasomotor abnormalities
What are some hypoperfusion symptoms of POTS?
What are some cardiopulmonary symptoms of POTS?
Exertional fatigue and breathlessness
What are some of the POTS symptoms that are due to cardiac ventricular baroreceptors?
- Postural neurocardiogenic symptoms
- profound episodic fatigue
What are dome superimposed situational depression symptoms of POTS
- patients feel miserable
- often ridiculed
- depondent about normal functioning
What are the diagnostic criteria for POTS?
30 point orthostatic rise in heart rate or maximum orthostatic heart rate >120/min and less than 10 mmHg drop in SBP
3 diagnostic tests for pots
- bedside postural vital signs
- tilt table testing
- holter monitor
Accelerated heart rate of __ -___ bpm due to postural challenge or daily activities is diagnostic of POTS
____ POTS is a milder form of the disaease with partial recovery in several years
POTS caused by ______ is chronic and potentially progressive
What are the treatments for POTS?
- High sodium diet
- periodic saline infusion
- Beta blockers
What medications are used in POTS to correct hyperadrenergic tone?
What type of beta blockers are used in POTs and why?
- Hydrophilic agents to minimize risk of fatigue
What agent is used for Insomina and BP in POTS?
- very helpful for insomnia, reduces supine BP but not upright BP
- Beta blockers before bed
Why are SSRIs used for POTS?
Serotonergic pathoways appear to mediate between vagal afferens and sympathetic efferents
what two methods can you use to enhance preload in POTS patients?
- continuous saline infusion
How do you enhance cardiovagal tone in a POTS patient?
Pyridostigmine- therapy is limited by gastrointestinal hypermotility symptoms
What would you do to optimize preload in a POTS patients
- High sodium diet