HYPOTENSION: Diagnosis and Management

Overview

Low blood pressure might seem desirable, and for some people, it causes no
problems. However, for many people, abnormally low blood pressure (hypotension)
can cause dizziness and fainting. In severe cases, low blood pressure can be life-
threatening.

A blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top
number (systolic) or 60 mm Hg for the bottom number (diastolic) is generally
considered low blood pressure.

The causes of low blood pressure can range from dehydration to serious medical or
surgical disorders. It's important to find out what's causing your low blood pressure so
that it can be treated.

Symptoms and causes

Symptoms

For some people, low blood pressure signals an underlying problem, especially when it
drops suddenly or is accompanied by signs and symptoms such as:

 Dizziness or lightheadedness
 Fainting (syncope)
 Blurred vision
 Nausea
 Fatigue
 Lack of concentration

Shock

Extreme hypotension can result in this life-threatening condition. Signs and symptoms
include:

 Confusion, especially in older people

 Cold, clammy, pale skin
 Rapid, shallow breathing
  Weak and rapid pulse

When to see a doctor

If you have indications of shock, seek emergency medical help.

If you have consistently low blood pressure readings but feel fine, your doctor is likely
just to monitor you during routine exams.

Even occasional dizziness or lightheadedness may be a relatively minor problem — the

result of mild dehydration from too much time in the sun or a hot tub, for example.
Still, it's important to see your doctor if you have signs or symptoms of hypotension
because they can point to more-serious problems. It can be helpful to keep a record of
your symptoms, when they occur and what you're doing at the time.

Causes

Blood pressure is a measurement of the pressure in your arteries during the active and
resting phases of each heartbeat.

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

Current guidelines identify normal blood pressure as lower than 120/80 mm Hg.

Throughout the day, blood pressure varies, depending on body position, breathing
rhythm, stress level, physical condition, medications you take, what you eat and drink,
and time of day. Blood pressure is usually lowest at night and rises sharply on waking.

Blood pressure: How low can you go?

What's considered low blood pressure for you may be normal for someone else. Most
doctors consider blood pressure too low only if it causes symptoms.

Some experts define low blood pressure as readings lower than 90 mm Hg systolic or
60 mm Hg diastolic. If either number is below that, your pressure is lower than normal.

A sudden fall in blood pressure can be dangerous. A change of just 20 mm Hg — a

drop from 110 systolic to 90 mm Hg systolic, for example — can cause dizziness and
fainting when the brain fails to receive an adequate supply of blood. And big plunges,
such as those caused by uncontrolled bleeding, severe infections or allergic reactions,
can be life-threatening.

Conditions that can cause low blood pressure

Medical conditions that can cause low blood pressure include:

 Pregnancy. Because the circulatory system expands rapidly during pregnancy,

blood pressure is likely to drop. This is normal, and blood pressure usually
returns to your pre-pregnancy level after you've given birth.
 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.
 Endocrine problems. Thyroid conditions such as parathyroid disease, adrenal
insufficiency (Addison's disease), low blood sugar (hypoglycemia) and, in some
cases, diabetes can trigger low blood pressure.
 Dehydration. When your body loses more water than it takes in, it can cause
weakness, dizziness and fatigue. Fever, vomiting, severe diarrhea, overuse of
diuretics and strenuous exercise can lead to dehydration.
 Blood loss. Losing a lot of blood, such as from a major injury or internal
bleeding, reduces the amount of blood in your body, leading to a severe drop in
blood pressure.
 Severe infection (septicemia). When an infection in the body enters the
bloodstream, it can lead to a life-threatening drop in bp called septic shock.
 Severe allergic reaction (anaphylaxis). Common triggers of this severe and
potentially life-threatening reaction include foods, certain medications, insect
venoms and latex. Anaphylaxis can cause breathing problems, hives, itching, a
swollen throat and a dangerous drop in blood pressure.
 Lack of nutrients in your diet. A lack of the vitamins B-12 and folate can keep
your body from producing enough red blood cells (anemia), causing low BP.

Medications that can cause low blood pressure

Some medications can cause low blood pressure, including:

 Water pills (diuretics), such as furosemide (Lasix) and hydrochlorothiazide

 Alpha blockers, such as prazosin (Minipress)
 Beta blockers, such as atenolol (Tenormin) and propranolol (Inderal)
  Drugs for Parkinson's disease, such as pramipexole (Mirapex) or those
containing levodopa
 Certain types of antidepressants (tricyclic antidepressants), including doxepin
(Silenor) and imipramine (Tofranil)
 Drugs for erectile dysfunction, including sildenafil (Revatio, Viagra) or tadalafil
(Adcirca, Cialis), particularly when taken with the heart medication nitroglycerin

Types of low blood pressure

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

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

is a sudden drop in blood pressure when you stand up from a sitting position or
after lying down.

Gravity causes blood to pool in your legs when you stand. Ordinarily, your body
compensates by increasing your heart rate and constricting blood vessels,
thereby ensuring that enough blood returns to your brain.

But in people with orthostatic hypotension, this compensating mechanism fails

and blood pressure falls, leading to dizziness, lightheadedness, blurred vision
and even fainting.

Orthostatic hypotension can occur for various reasons, including dehydration,

prolonged bed rest, pregnancy, diabetes, heart problems, burns, excessive heat,
large varicose veins and certain neurological disorders.

A number of medications also can cause orthostatic 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.

Orthostatic hypotension is especially common in older adults, but it also affects

young, otherwise healthy people who stand up suddenly after sitting with their
legs crossed for long periods or after squatting for a time.

It's also possible to have delayed orthostatic hypotension, with signs and
symptoms developing 5 to 10 minutes after a change in posture. This might be a
milder form of the condition, or it could be an early stage of it.
  Low blood pressure after eating (postprandial hypotension). This sudden drop
in blood pressure after eating affects mostly older adults.

Blood flows to your digestive tract after you eat. Ordinarily, your body increases
your heart rate and constricts 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 might help reduce symptoms.

 Low blood pressure from faulty brain signals (neurally mediated hypotension).
This disorder, which causes a blood pressure drop after standing for long
periods, mostly affects young adults and children. It seems to occur because of a
miscommunication between the heart and the brain.

 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. It's associated with having very high blood pressure while lying down.

Risk factors

Low blood pressure (hypotension) can occur in 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

adults older than 65. Neurally mediated hypotension primarily affects children
and younger adults.


 Medications. People who take certain medications, for example, high blood
pressure medications such as alpha blockers, have a greater risk of low blood
pressure.


 Certain diseases. Parkinson's disease, diabetes and some heart conditions put
you at a greater risk of developing low blood pressure.
Complications

Even moderate forms of low blood pressure can cause dizziness, weakness, fainting
and a risk of injury from falls.

And severely low blood pressure can deprive your body of enough oxygen to carry out
its normal functions, leading to damage to your heart and brain.

Diagnosis

Tilt table test

The goal in testing for low blood pressure is to find the underlying cause. Besides
taking your medical history, doing a physical exam and measuring your blood pressure,
your doctor might recommend the following:

 Blood tests. These can provide information about your overall health as well as
whether you have low blood sugar (hypoglycemia), high blood sugar
(hyperglycemia or diabetes) or a low red blood cell count (anemia), all of which
can cause lower than normal blood pressure.
 Electrocardiogram (ECG). During this painless, noninvasive test, soft, sticky
patches (electrodes) are attached to the skin of your chest, arms and legs. The
patches detect your heart's electrical signals while a machine records them on
graph paper or displays them on a screen.

An ECG, 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 have had one in the past.
 Heart rhythm abnormalities come and go, and an ECG might not find them. You
might be asked to wear a 24-hour Holter monitor to record your heart's
electrical activity as you go about your daily routine.

 Echocardiogram. This noninvasive exam, which includes an ultrasound of your

chest, shows detailed images of your heart's structure and function.

Ultrasound waves are transmitted, and their echoes are recorded with a device
called a transducer, which is held outside your body. A computer uses the
information from the transducer to create moving images on a video monitor.

 Stress test. Some heart problems that 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 walk on a treadmill or do some other form of exercise. You
might 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're trying to inflate a balloon.
 Tilt table test. If you have low blood pressure on standing, or from faulty brain
signals (neurally mediated hypotension), a tilt table test can evaluate 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 horizontal to a standing position.

Treatment

Compression stockings
Low blood pressure that either doesn't cause signs or symptoms or causes only mild
symptoms rarely requires treatment.

If you have symptoms, treatment depends on the underlying cause. For instance,
when low blood pressure is caused by medications, treatment usually involves
changing or stopping the medication or lowering the dose.

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

 Use more salt. Experts usually recommend limiting salt in your diet because
sodium can raise blood pressure, sometimes dramatically. 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 increasing the salt in your diet.

 Drink more water. Fluids increase blood volume and help prevent dehydration,
both of which are important in treating hypotension.

 Wear compression stockings. The elastic stockings commonly used to relieve

the pain and swelling of varicose veins can help reduce the pooling of blood in
your legs.

 Medications. Several medications can be used to treat low blood pressure that
occurs when you stand up (orthostatic hypotension). For example, the drug
fludrocortisone, which boosts your blood volume, is often used to treat this
form of low blood pressure.

Doctors often use the drug midodrine (Orvaten) 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.

Lifestyle and home remedies

Depending on the reason for your low blood pressure, you might be able to reduce or
prevent symptoms.
 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.

 Eat 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 using more salt but you don't like a lot of salt on your
food, try using natural soy sauce or adding dry soup mixes to dips and dressings.

 Pay attention to your body positions. Gently move from a prone or squatting to
a standing position. Don't sit with your legs crossed.

Before arising 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 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.

Your doctor also might recommend drinking caffeinated coffee or tea with
meals to temporarily raise blood pressure. But because caffeine can cause other
problems, check with your doctor before drinking more caffeinated beverages.