Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications

Abstract

Orthostatic hypotension (OH) is an abnormal blood pressure response to standing, which is associated with an increased risk of adverse outcomes such as syncope, falls, cognitive impairment, and mortality. Medical therapy is one the most common causes of OH, since numerous cardiovascular and psychoactive medications may interfere with the blood pressure response to standing, leading to drug-related OH. Additionally, hypotensive medications frequently overlap with other OH risk factors (e.g., advanced age, neurogenic autonomic dysfunction, and comorbidities), thus increasing the risk of symptoms and complications. Consequently, a medication review is recommended as a first-line approach in the diagnostic and therapeutic work-up of OH, with a view to minimizing the risk of drug-related orthostatic blood pressure impairment. If symptoms persist after the review of hypotensive medications, despite adherence to non-pharmacological interventions, specific drug treatment for OH can be considered. In this narrative review we present an overview of drugs acting on the cardiovascular and central nervous system that may potentially impair the orthostatic blood pressure response and we provide practical suggestions that may be helpful to guide medical therapy optimization in patients with OH. In addition, we summarize the available strategies for drug treatment of OH in patients with persistent symptoms despite non-pharmacological interventions.

Predictive value of attended automated office blood pressure and resting pulse rate for mortality in community‐dwelling octogenarians: Minhang study

“…We also noticed that only the participants with higher SBP (>144 mmHg), but not those with lower SBP, had an increased risk of cardiovascular mortality. The potential for side effects with antihypertensive therapy in oldest old had been noticed for a long time, including orthostatic hypotension, 20 accelerated cognitive decline, 21 and etc Although the aggressive BP lowering in the SPRINT trail did reduce the risk of cardiovascular events and all‐cause mortality in robust elders, the incidence of kidney injury and syncope were still high. The PARTAGE study found that the institutionalized individuals older than 80 years who were with lower SBP and under the treatment with 2 or more BP‐lowering agents resulted in a higher risk of mortality 22 .…”

Orthostatic Hypotension and Orthostatic Intolerance Symptoms in Geriatric Rehabilitation Inpatients, RESORT

“…Factors including physical inactivity and peripheral vascular disease predisposing to peripheral venous pooling in addition to dehydration as a result of recent acute illness or medication such as diuretics may influence symptom prevalence in geriatric rehabilitation inpatients. 9,32,38 Conversely, asymptomatic OH may be indicative of adequate cerebral perfusion autoregulation on change in posture 11,39 or habituation to orthostatic intolerance symptoms. 40 Moreover, symptoms experienced by inpatients without OH may have corresponded with initial OH or rapid changes in blood pressure, 41 which can be accurately detected only by continuous blood pressure monitoring.…”

“…44 Hospitalized inpatients typically take a higher number of medications, contributing to OH and symptoms. 9 Frequently prescribed cardiovascular and psychotropic medications in older adults commonly cause side effects of OH and orthostatic intolerance symptoms to prevail. 43,45 Lack of association between cardiovascular and psychotropic medication and OH or symptoms may indicate adequate blood pressure management of inpatients.…”

“…OH is characterized by the inability to maintain blood pressure in an upright position after standing up and is defined by a drop in systolic blood pressure (SBP) by !20 mm Hg and/or a drop in diastolic blood pressure (DBP) by !10 mm Hg within 3 minutes of a postural change from supine to an upright position. 7 The etiology of OH is multifactorial, and known risk factors for OH in older adults include chronological age, 8 polypharmacy, 9 frailty, 10 and multimorbidity. 8 Symptoms of orthostatic intolerance are commonly associated with OH and may occur as a consequence of orthostasis-related cerebral hypoperfusion causing deprivation of cerebral oxygen.…”

Incidence of Orthostatic Hypotension in Schizophrenic Patients Using Antipsychotics at Sambang Lihum Mental Health Hospital, South Kalimantan

“…Neurogenic and non-neurogenic factors can cause orthostatic hypotension. Drugs, especially antipsychotics, are the most common cause of nonneurogenic orthostatic hypotension 10 . Antipsychotics that can cause orthostatic hypotension are considered antipsychotics that act on α-1 postsynaptic receptors like typical antipsychotics 11 ; however, supporting data is still very limited.…”