Hypotension

Definition
Low blood pressure, also called hypotension, would seem to be something to strive
for. After all, high blood pressure (hypertension) is a well-known risk factor for heart
disease and other problems. In fact, in recent years there has been an ongoing
downward revision of what is considered a normal blood pressure reading. A blood
pressure less than 120/80 millimeters of mercury (mm Hg) is now considered normal
and optimal for good health.

So, it's easy to understand why you might assume the lower the better when it comes
to blood pressure. And it's true that for some people — those who exercise and are in
top physical condition — low blood pressure is a sign of health and fitness. But that's
not always the case.

For many people, low blood pressure can cause dizziness and fainting or indicate
serious heart, endocrine or neurological disorders. Severely low blood pressure can
deprive the brain and other vital organs of oxygen and nutrients, leading to a life-
threatening condition called shock.

Symptoms
Some people with low blood pressure are in peak physical condition with strong
cardiovascular systems and a reduced risk of heart attack and stroke. But low blood
pressure can also signal an underlying problem, especially when it drops suddenly or
is accompanied by signs and symptoms such as:

 Dizziness or lightheadedness
 Fainting (syncope)
 Lack of concentration
 Blurred vision
 Nausea
 Cold, clammy, pale skin
 Rapid, shallow breathing
 Fatigue
 Depression
 Thirst

Causes
Blood pressure is a measurement of the pressure in your arteries during the active and
resting phases of each heartbeat. Here's what the numbers mean:

 Systolic pressure. The first number in a blood pressure reading, this is the
amount of pressure your heart generates when pumping blood through your
arteries to the rest of your body.
  Diastolic pressure. The second number in a blood pressure reading, this refers
to the amount of pressure in your arteries when your heart is at rest between
beats.

Although you can get an accurate blood pressure reading at any given time, blood
pressure isn't static. It can vary considerably in a short amount of time — sometimes
from one heartbeat to the next, depending on body position, breathing rhythm, stress
level, physical condition, medications you take, what you eat and drink, and even time
of day. Blood pressure is usually lowest at night and rises sharply on waking.

Blood pressure: How low can you go?

Current guidelines identify normal blood pressure as lower than 120/80 — many
experts think 115/75 is optimal. Higher readings indicate increasingly serious risks of
cardiovascular disease. Low blood pressure, on the other hand, is much harder to
quantify.

Some experts define low blood pressure as readings lower than 90 systolic or 60
diastolic — you need to have only one number in the low range for your blood
pressure to be considered lower than normal. In other words, if your systolic pressure
is a perfect 115, but your diastolic pressure is 50, you're considered to have lower than
normal pressure.

Yet this can be misleading because what's considered low blood pressure for you may
be normal for someone else. For that reason, doctors often consider chronically low
blood pressure too low only if it causes noticeable symptoms.

On the other hand, a sudden fall in blood pressure can be dangerous. A change of just
20 mm Hg — a drop from 130 systolic to 110 systolic, for example — can cause
dizziness and fainting when the brain fails to receive an adequate supply of blood.
And big plunges, especially those caused by uncontrolled bleeding, severe infections
or allergic reactions can, be life-threatening.

Causes of low blood pressure vary

Athletes and people who exercise regularly tend to have lower blood pressure than do
people who aren't as fit. So, in general, do nonsmokers and people who eat well and
maintain a normal weight.

But in some instances, low blood pressure can be a sign of serious, even life-
threatening disorders. The American Heart Association considers the following as
possible causes of low blood pressure:

 Pregnancy. Because a woman's circulatory system expands rapidly during

pregnancy, blood pressure is likely to drop. In fact, during the first 24 weeks
of pregnancy, systolic pressure commonly drops by five to 10 points and
diastolic pressure by as much as 10 to 15 points.
 Medications. Many drugs can cause low blood pressure, including diuretics
and other drugs that treat high blood pressure; heart medications such as beta
blockers; drugs for Parkinson's disease; tricyclic antidepressants; sildenafil
(Viagra), particularly in combination with nitroglycerine; narcotics; and
 alcohol. Some over-the-counter medications can cause low blood pressure
when taken in combination with medications used to treat high blood pressure.
 Heart problems. Some heart conditions that can lead to low blood pressure
include extremely low heart rate (bradycardia), heart valve problems, heart
attack and heart failure. These conditions may cause low blood pressure
because they prevent your body from being able to circulate enough blood.
 Endocrine problems. An underactive thyroid (hypothyroidism) or overactive
thyroid (hyperthyroidism) can cause low blood pressure. In addition, other
conditions, such as adrenal insufficiency (Addison's disease), low blood sugar
(hypoglycemia), and in some cases, diabetes, can trigger low blood pressure.
 Dehydration. When you become dehydrated, your body loses more water
than it takes in. Even mild dehydration can cause weakness, dizziness and
fatigue. Fever, vomiting, severe diarrhea, overuse of diuretics and strenuous
exercise can all lead to dehydration. Far more serious is hypovolemic shock, a
life-threatening complication of dehydration. It occurs when low blood
volume causes a sudden drop in blood pressure and a corresponding reduction
in the amount of oxygen reaching your tissues. If untreated, severe
hypovolemic shock can cause death within a few minutes or hours.
 Blood loss. Losing a lot of blood from major injury or severe internal bleeding
reduces the amount of blood in your body, leading to a severe drop in blood
pressure.
 Severe infection (septicemia). Septicemia can happen when an infection in
the body enters the bloodstream. Lung, abdomen or urinary tract infections are
usually the cause of septicemia. These conditions can lead to a life-threatening
drop in blood pressure called septic shock.
 Allergic reaction (anaphylaxis). Anaphylaxis is a severe and potentially life-
threatening allergic reaction. Common triggers of anaphylaxis include foods,
certain medications, insect venoms and latex. Anaphylaxis can cause breathing
problems, hives, itching, a swollen throat and a drop in blood pressure.
 Nutritional deficiencies. A lack of the vitamins B-12 and folate can cause
anemia, a condition in which your body doesn't produce enough red blood
cells. In addition to making you feel tired because you're not getting enough
oxygen, anemia can lead to low blood pressure.

Types of low blood pressure

Doctors often break down low blood pressure (hypotension) into different categories,
depending on the causes and other factors. Some types of low blood pressure include:

 Low blood pressure on standing up (postural or orthostatic hypotension).

This is a sudden drop in blood pressure when you stand up from a sitting
position or if you stand up after lying down. Ordinarily, blood pools in your
legs whenever you stand, but your body compensates for this by increasing
your heart rate and constricting blood vessels, thereby ensuring that enough
blood returns to your brain. But in people with postural hypotension, this
compensating mechanism fails and blood pressure falls, leading to dizziness,
lightheadedness, blurred vision and even fainting.

Postural hypotension can occur for a variety of reasons including dehydration,

prolonged bed rest, pregnancy, diabetes, heart problems, burns, excessive heat,
large varicose veins and certain neurological disorders. A number of
 medications can also cause postural hypotension, particularly drugs used to
treat high blood pressure — diuretics, beta blockers, calcium channel blockers
and angiotensin-converting enzyme (ACE) inhibitors — as well as
antidepressants and drugs used to treat Parkinson's disease and erectile
dysfunction.

Postural hypotension is especially common in older adults, with as many as 20

percent of those over age 65 experiencing postural hypotension. But postural
hypotension can also affect young, otherwise healthy people who stand up
suddenly after sitting with their legs crossed for long periods or after working
for a time in a squatting position.

 Low blood pressure due to nervous system damage (multiple system

atrophy with orthostatic hypotension). Also called Shy-Drager syndrome,
this rare disorder causes progressive damage to the autonomic nervous system,
which controls involuntary functions such as blood pressure, heart rate,
breathing and digestion. Although multiple system atrophy can be associated
with muscle tremors, slowed movement, problems with coordination and
speech, and incontinence, its main characteristic is severe orthostatic
hypotension in combination with very high blood pressure when lying down.
Multiple system atrophy can't be cured and usually proves fatal within seven
to 10 years of diagnosis.
 Low blood pressure after eating (postprandial hypotension). A problem
that almost exclusively affects older adults, postprandial hypotension is a
sudden drop in blood pressure after eating. Just as gravity pulls blood to your
feet when you stand, a large amount of blood flows to your digestive tract
after you eat. Ordinarily, your body counteracts this by increasing your heart
rate and constricting certain blood vessels to help maintain normal blood
pressure. But in some people these mechanisms fail, leading to dizziness,
faintness and falls. Postprandial hypotension is more likely to affect people
with high blood pressure or autonomic nervous system disorders such as
Parkinson's disease. Lowering the dose of blood pressure drugs and eating
small, low-carbohydrate meals may help reduce symptoms.
 Low blood pressure from faulty brain signals (neurally mediated
hypotension). Unlike orthostatic hypotension — which occurs when you
stand up from a sitting or lying position — this disorder causes blood pressure
to drop after standing for long periods, leading to symptoms such as dizziness,
nausea and fainting. Although the end result is similar, neurally mediated
hypotension differs from orthostatic hypotension in other important respects:
It primarily affects young people, for instance, and rather than resulting from
failed blood pressure regulation, it seems to occur because of a
miscommunication between the heart and the brain. When you stand for
extended periods, your blood pressure falls as blood pools in your legs.
Normally, your body then makes adjustments to normalize your blood
pressure. But in people with neurally mediated hypotension, nerves in the
heart's left ventricle actually signal the brain that blood pressure is too high,
rather than too low, and so the brain lessens the heart rate, decreasing blood
pressure even further. This causes more blood to pool in the legs and less
blood to reach the brain, leading to lightheadedness and fainting.
Risk factors
Low blood pressure (hypotension) can happen to anyone, though certain types of low
blood pressure are more common depending on your age or other factors:

 Age. Drops in blood pressure on standing or after eating occur primarily in

older adults. Orthostatic hypotension happens after standing up, while
postprandial hypotension happens after eating a meal. Neurally mediated
hypotension happens as a result of a miscommunication between the brain and
heart. It primarily affects children and younger adults.
 Medications. People who take certain medications, such as high blood
pressure medication, have a greater risk of low blood pressure.
 Certain diseases. Parkinson's disease and some heart conditions put you at a
greater risk of developing low blood pressure.

When to seek medical advice

In many instances, low blood pressure isn't serious. If you have consistently low
readings but feel fine, your doctor is likely to monitor you during routine exams. Even
occasional dizziness or lightheadedness may be relatively minor — the result of mild
dehydration, low blood sugar or too much time in the sun or a hot tub, for example. In
these situations, it's not a matter so much of how far, but of how quickly, your blood
pressure drops. Still, it's important to see your doctor if you experience any signs or
symptoms of hypotension because they sometimes can point to more serious
problems. It can be helpful to keep a record of your symptoms, when they occur and
what you were doing at the time. If these occur at times that may endanger you or
others, you should talk to your doctor.

Tests and diagnosis

The goal in evaluating low blood pressure is to find the underlying cause. This helps
determine the correct treatment and identify any heart, brain or nervous system
problems that may be responsible for lower than normal readings. To help reach a
diagnosis, your doctor may recommend one or more of the following:

 Blood tests. These can provide a certain amount of information about your
overall health as well as whether you have low blood sugar (hypoglycemia) or
a low number of red blood cells (anemia), both of which can cause lower than
normal blood pressure.
 Electrocardiogram (ECG, EKG). This noninvasive test, which can be
performed in your doctor's office, detects irregularities in your heart rhythm,
structural abnormalities in your heart, and problems with the supply of blood
and oxygen to your heart muscle. It can also tell if you're having a heart attack
or if you've had a heart attack in the past. Sometimes you may be asked to
wear a 24-hour Holter monitor to record your heart's electrical activity as you
go about your daily routine.
  Echocardiogram. Using the same technology that allows you to view a fetus
in the womb, an echocardiogram uses sound waves to produce images of your
heart that may show abnormalities in your heart muscle or valves.
 Stress test. Some heart problems which can cause low blood pressure are
easier to diagnose when your heart is working harder than when it's at rest.
During a stress test, you'll exercise, such as walking on a treadmill. (Or, you
may be given medication to make your heart work harder if you're unable to
exercise.) When your heart is working harder, your heart will be monitored
with electrocardiography or echocardiography. Your blood pressure also may
be monitored.
 Valsalva maneuver. This noninvasive test checks the functioning of your
autonomic nervous system by analyzing your heart rate and blood pressure
after several cycles of a type of deep breathing: You take a deep breath and
then force the air out through your lips, as if you were trying to blow up a stiff
balloon.
 Tilt-table test. If you have low blood pressure on standing, or from faulty
brain signals (neurally mediated hypotension), your doctor may suggest a tilt-
table test, which evaluates how your body reacts to changes in position.
During the test, you lie on a table that's tilted to raise the upper part of your
body, which simulates the movement from a prone to a standing position.

Complications
Even moderate forms of low blood pressure can seriously affect quality of life,
leading not only to dizziness and weakness but also to fainting and a risk of injury
from falls. And severely low blood pressure from any cause can deprive your body of
enough oxygen to carry out its normal functions, leading to damage to your heart and
brain.

Treatments and drugs

Low blood pressure that doesn't cause signs or symptoms rarely requires treatment. In
symptomatic cases, the appropriate therapy depends on the underlying cause, and
doctors usually try to address the primary health problem — dehydration, heart
failure, diabetes or hypothyroidism, for example — rather than low blood pressure
itself. When low blood pressure is caused by medications, treatment usually involves
changing the dose of the medication or stopping it entirely.

If it's not clear what's causing low blood pressure or no effective treatment exists, the
goal is to raise your blood pressure and reduce signs and symptoms. Depending on
your age, health status and the type of low blood pressure you have, this may be
accomplished in several ways:

 Use more salt. Experts usually recommend limiting the amount of salt in your
diet because sodium can raise blood pressure, sometimes dramatically. But for
people with low blood pressure, that can be a good thing. But because excess
sodium can lead to heart failure, especially in older adults, it's important to
check with your doctor before upping your salt intake.
  Drink more water. Although nearly everyone can benefit from drinking
enough water, this is especially true if you have low blood pressure. Fluids
increase blood volume and help prevent dehydration, both of which are
important in treating hypotension.
 Use compression stockings. The same elastic stockings and leotards
commonly used to relieve the pain and swelling of varicose veins may help
reduce the pooling of blood in your legs.
 Medications. Several medications, either used alone or together, can be used
to treat low blood pressure that occurs when you stand up (orthostatic
hypotension). For example, the drug fludrocortisone is often used to treat this
form of low blood pressure. This drug helps boost your blood volume, which
raises blood pressure. Doctors often use the drug midodrine to raise standing
blood pressure levels in people with chronic orthostatic hypotension. It works
by restricting the ability of your blood vessels to expand, which raises blood
pressure. Other drugs, such as pyridostigmine, nonsteroidal anti-inflammatory
drugs (NSAIDs), caffeine and erythropoietin are sometimes used, too, either
alone or with other drugs.

Lifestyle and home remedies

Depending on the reason for your low blood pressure, you may be able to take certain
steps to help reduce or even prevent symptoms. Some suggestions include:

 Drink more water, less alcohol. Alcohol is dehydrating and can lower blood
pressure, even if you drink in moderation. Water, on the other hand, combats
dehydration and increases blood volume.
 Follow a healthy diet. Get all the nutrients you need for good health by
focusing on a variety of foods, including whole grains, fruits, vegetables, and
lean chicken and fish. If your doctor suggests increasing your sodium intake
but you don't like a lot of salt on your food, try using natural soy sauce — a
whopping 1,200 milligrams of sodium per tablespoon — or adding dry soup
mixes, also loaded with sodium, to dips and dressings.
 Go slow. You may be able to reduce the dizziness and lightheadedness that
occurs with low blood pressure on standing by taking it easy when you move
from a prone to a standing position. Before getting out of bed in the morning,
breathe deeply for a few minutes and then slowly sit up before standing.
Sleeping with the head of your bed slightly elevated also can help fight the
effects of gravity. If you begin to get symptoms while standing, cross your
thighs in a scissors fashion and squeeze or put one foot on a ledge or chair and
lean as far forward as possible. These maneuvers encourage blood to flow
from your legs to your heart.
 Eat small, low-carb meals. To help prevent blood pressure from dropping
sharply after meals, eat small portions several times a day and limit high-
carbohydrate foods such as potatoes, rice, pasta and bread. Drinking
caffeinated coffee or tea with meals may temporarily raise blood pressure, in
some cases by as much as 3 to 14 millimeters of mercury (mm Hg). But
because caffeine can cause other problems, check with your doctor before
increasing your caffeine intake.