11 hypotension

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Hypotension

In physiology and medicine , hypotension is low bloodpressure , especially in the arteries of the systemic cir-culation .[1] Blood pressure is the force of blood pushingagainst the walls of the arteries as the heart pumps outblood. Hypotension is generally considered systolic bloodpressure less than 90 millimeters of mercury (mm Hg) ordiastolic less than 60 mm Hg. [2][3] However, in practice,blood pressure is considered too low only if noticeablesymptoms are present. [4]

Hypotension is the opposite of hypertension , whichis high blood pressure. It is best understood as aphysiological state, rather than a disease. It is often as-sociated with shock , though not necessarily indicative ofit.

For some people who exerciseandare in top physical con-dition, low blood pressure is a sign of good health andtness. [5] For many people, excessively low blood pres-sure can cause dizziness and fainting or indicate seriousheart, endocrine or neurological disorders . Severely lowblood pressure can deprive the brain and other vital or-gans of oxygen and nutrients, leading to a life-threateningcondition called shock .

1 Signs and symptoms

The cardinal symptoms of hypotension includelightheadedness or dizziness .[6]

If the blood pressure is sufficiently low, fainting and oftenseizures occur.

Low blood pressure is sometimes associated with certainsymptoms, many of which are related to causes ratherthan effects of hypotension:

chest pain

shortness of breath

irregular heartbeat

fever higher than 38.3 C (101 F)

headache

stiff neck

severe upper back pain

cough with phlegm

prolonged diarrhea or vomiting

dyspepsia (indigestion)

dysuria (painful urination)

adverse effect of medications

acute, life-threatening allergic reaction

seizures

loss of consciousness

profound fatigue

temporary blurring or loss of vision

connective tissue disorder Ehlers-Danlos Syndrome

Black tarry stools

2 Causes

Low blood pressure can be caused by low blood volume,hormonal changes, widening of blood vessels, medicineside effects, anemia , heart problems or endocrine prob-lems.

Reduced blood volume, hypovolemia , is the most com-mon cause of hypotension. This can result fromhemorrhage ; insufficient uid intake, as in starvation; orexcessive uid losses from diarrhea or vomiting. Hypo-volemia is often induced by excessive use of diuretics .Low blood pressure may also be attributed to heat stroke.The body may have enough uid but does not retain elec-trolytes. Absence of perspiration, light headedness anddark coloured urine are also indicators.

Other medications can produce hypotension by differ-

ent mechanisms. Chronic use of alpha blockers or betablockers can lead to hypotension. Beta blockers can causehypotension both by slowing the heart rate and by de-creasing the pumping ability of the heart muscle.

Decreased cardiac output despite normal blood volume,due to severe congestive heart failure , large myocardialinfarction , heart valve problems, or extremely low heartrate ( bradycardia ), often produces hypotension and canrapidly progress to cardiogenic shock . Arrhythmias oftenresult in hypotension by this mechanism.

Some heart conditions can lead to low blood pressure,including extremely low heart rate (bradycardia), heart

valve problems, heart attack and heart failure. These con-ditions may cause low blood pressure because they pre-vent the body from being able to circulate enough blood.

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2 6 TREATMENT

Excessive vasodilation , or insufficient constriction of theresistance blood vessels (mostly arterioles ), causes hy-potension. This can be due to decreased sympathetic ner-vous system output or to increased parasympathetic activ-ity occurring as a consequence of injury to the brain orspinal cord or of dysautonomia , an intrinsic abnormalityin autonomic system functioning. Excessive vasodilationcan also result from sepsis , acidosis , or medications, suchas nitrate preparations , calcium channel blockers , or AT1receptor antagonists ( Angiotensin II acts on AT1 recep-tors ). Many anesthetic agents and techniques, includingspinal anesthesia and most inhalational agents , producesignicant vasodilation .

Meditation , yoga, or other mental-physiological disci-plines may reduce hypotensive effects. [7]

Lower blood pressure is a side effect of certainbotanicals ,[8] which can also interact with hypoten-

sive medications. An example is the theobrominein Theobroma cacao , which lowers blood pressure [9]

through its actions as both a vasodilator and a diuretic ,[10]

and has been used to treat high blood pressure. [11][12]

3 Pathophysiology

Blood pressure is continuously regulated by theautonomic nervous system , using an elaborate networkof receptors , nerves , and hormones to balance the effectsof the sympathetic nervous system , which tends to raiseblood pressure, and the parasympathetic nervous system ,which lowers it. The vast and rapid compensationabilities of the autonomic nervous system allow normalindividuals to maintain an acceptable blood pressure overa wide range of activities and in many disease states.

4 Syndromes

Orthostatic hypotension , also called postural hypotension ,is a common form of low blood pressure. It occurs af-ter a change in body position, typically when a personstands up from either a seated or lying position. It is usu-ally transient and represents a delay in the normal com-pensatory ability of the autonomic nervous system. It iscommonly seen in hypovolemia and as a result of vari-ous medications. In addition to blood pressure-loweringmedications, many psychiatric medications, in particularantidepressants , can have this side effect. Simple bloodpressure and heart rate measurements while lying, seated,and standing (with a two-minute delay in between eachposition change) can conrm the presence of orthostatichypotension. Orthostatic hypotension is indicated if there

is a drop in 20 mmHg of systolic pressure (and a 10mmHg drop in diastolic pressure in some facilities) and a20 beats per minute increase in heart rate.

Neurocardiogenic syncope is a form of dysautonomiacharacterized by an inappropriate drop in blood pressurewhile in the upright position. Neurocardiogenic syncopeis related to vasovagal syncope in that both occur as a re-sult of increased activity of the vagus nerve , the mainstayof the parasympathetic nervous system.

Another, but rarer form, is postprandial hypotension, adrastic decline in blood pressure that occurs 30 to 75minutes after eating substantial meals. [13] When a greatdeal of blood is diverted to the intestines (a kind of"splanchnic blood pooling) to facilitate digestion andabsorption , thebody must increase cardiac output and pe-ripheral vasoconstriction to maintain enough blood pres-sure to perfuse vital organs, such as the brain. Postpran-dial hypotension is believed caused by the autonomic ner-vous system not compensating appropriately, because ofaging or a specic disorder.

Hypotension is a feature of Flammer syndrome which ischaracterized by cold hands and feet and predisposes tonormal tension glaucoma .[14]

5 Diagnosis

For most adults, the healthiest blood pressure is at orbelow 120/80 mmHg. A small drop in blood pres-sure, even as little as 20 mmHg, can result in transienthypotension. [15]

Evaluation of neurocardiogenicsyncope isdone witha tilttable test .

6 Treatment

The treatment for hypotension depends on its cause.Chronic hypotension rarely exists as more than a symp-tom. Asymptomatic hypotension in healthy people usu-ally does not require treatment. Adding electrolytes to adiet can relieve symptoms of mild hypotension. A morn-ing dose of caffeine can also be effective. In mild cases,

where the patient is still responsive, laying the person indorsal decubitus (lying on the back) position and liftingthe legs increases venous return, thus making more bloodavailable to critical organs in the chest and head. TheTrendelenburg position , though used historically, is nolonger recommended. [16]

Hypotensive shock treatment always follows the rst fourfollowing steps. Outcomes, in terms of mortality, are di-rectly linked to the speed that hypotension is corrected.Still-debated methods are in parentheses, as are bench-marks for evaluating progress in correcting hypotension.A study [17] on septic shock provided the delineation of

these general principles. However, since it focuses on hy-potension due to infection, it is not applicable to all formsof severe hypotension.
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1. Volume resuscitation (usually with crystalloid )

2. Blood pressure support with a vasopressor (all seemequivalent) [18]

3. Ensure adequate tissue perfusion (maintain SvO2

>70 with use of blood or dobutamine)

4. Address the underlying problem (i.e. antibiotic forinfection, stent or CABG (coronary artery bypassgraft surgery) for infarction, steroids for adrenal in-sufficiency , etc...)

Medium-term (and less well-demonstrated) treatments ofhypotension include:

Blood sugar control (80150 by one study)

Early nutrition (by mouth or by tube to prevent ileus ) Steroid support

7 See also

Dysautonomia

Hypotensive transfusion reaction

Orthostatic intolerance

8 References

[1] TheFreeDictionary > hypotension . Citing: The AmericanHeritage Science Dictionary Copyright 2005

[2] Diseases and Conditions Index Hypotension . NationalHeart Lung and Blood Institute. September 2008. Re-trieved 2008-09-16.

[3] Low blood pressure (hypotension) Denition . May-oClinic.com . Mayo Foundation for Medical Education andResearch. 2009-05-23. Retrieved 2010-10-19. |rst1=missing |last1= in Authors list ( help )

[4] Low blood pressure (hypotension) Causes . May-oClinic.com . Mayo Foundation for Medical Education andResearch. 2009-05-23. Retrieved 2010-10-19. |rst1=missing |last1= in Authors list ( help )

[5] Low blood pressure (hypotension)" . BUPA.co.uk .

[6] What Are the Signs and Symptoms of Hypotension?" .nhlbi.nih.gov . National Institutes of Health . November 1,2010. Retrieved 2014-02-17.

[7] Joel A. DeLisa, Bruce M. Gans, Nicholas E. Walsh (edi-tors) (2005). 19. Physical Medicine and Rehabilitation: Principles and Practice 1. Lippincott Williams & Wilkins.p. 468.

[8] Tabassum, Nahida; Feroz Ahmad (2011). Role of nat-ural herbs in the treatment of hypertension . Phar-macognosy Review 5 (9): 3040. doi:10.4103/0973-7847.79097 . PMC 3210006 . PMID 22096316 .

[9] Mitchell ES, Slettenaar M, vd Meer N, Transler C, JansL, Quadt F, Berry M.; Slettenaar; Vd Meer; Transler;Jans; Quadt; Berry (2011). Differential contributions oftheobromine and caffeine on mood, psychomotor perfor-mance and blood pressure. Physiol. Behav. 104 (5):81622. doi:10.1016/j.physbeh.2011.07.027 . PMID21839757 . Theobromine ... lowered blood pressure rela-tive to placebo

[10] William Marias Malisoff (1943). Dictionary of Bio-Chemistry and Related Subjects . Philosophical Library.pp. 311, 530, 573.

[11] Theobromine Chemistry Theobromine in Chocolate .Chemistry.about.com (2013-05-12). Retrieved on 2013-05-30.

[12] Kelly, Caleb J (2005). Effects of theobromine should beconsidered in future studies. American Journal of Clin-ical Nutrition 82 (2): 4867; author reply 4878. PMID16087999 .

[13] Merck Manual Home Edition. Postprandial Hypoten-sion. Last accessed October 26, 2011.

[14] Katarzyna Konieczka, Robert Rich et al.: Flammer syn-drome. EPMA Journal 2014; 5:11

[15] Chobanian AV, Bakris GL, Black HR, Cushman WC,Green LA, Izzo JL, Jones DW, Materson BJ, Oparil

S, Wright JT, Roccella EJ; Bakris; Black; Cush-man; Green; Izzo Jr; Jones; Materson; Oparil;Wright Jr; Roccella; Joint National Committee OnPrevention; National High Blood Pressure EducationProgram Coordinating Committee (December 2003).Seventh report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure . Hypertension 42 (6): 120652. doi:10.1161/01.HYP.0000107251.49515.c2 . PMID14656957 . Retrieved 2009-11-03.

[16] Kettaneh, Nicolas (30 October 2008). BestBets: Useof the Trendelenburg Position to Improve Hemodynam-ics During Hypovolemic Shock . Grand Rapids Medical Education & Research/Michigan State University .

[17] Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A,Knoblich B, Peterson E, Tomlanovich M; Nguyen; Havs-tad; Ressler; Muzzin; Knoblich; Peterson; Tomlanovich;Early Goal-Directed Therapy Collaborative Group (2001-11-08). Early goal-directed therapy in the treatment ofsevere sepsis and septic shock . N Engl J Med. (NEJM)345 (19): 136877. doi:10.1056/NEJMoa010307 .PMID 11794169 .

[18] Havel, C; Arrich, J; Losert, H; Gamper, G; Mllner, M;Herkner, H (2011-05-11). Herkner, Harald, ed. Va-sopressors for hypotensive shock. Cochrane databaseof systematic reviews (Online) 5 (5): CD003709.doi:10.1002/14651858.CD003709.pub3 . PMID21563137 .
https://www.ncbi.nlm.nih.gov/pubmed/21563137https://en.wikipedia.org/wiki/PubMed_Identifierhttps://dx.doi.org/10.1002%252F14651858.CD003709.pub3https://en.wikipedia.org/wiki/Digital_object_identifierhttps://www.ncbi.nlm.nih.gov/pubmed/11794169https://en.wikipedia.org/wiki/PubMed_Identifierhttps://dx.doi.org/10.1056%252FNEJMoa010307https://en.wikipedia.org/wiki/Digital_object_identifierhttps://en.wikipedia.org/wiki/The_New_England_Journal_of_Medicinehttp://content.nejm.org/cgi/content/full/345/19/1368http://content.nejm.org/cgi/content/full/345/19/1368http://www.bestbets.org/bets/bet.php?id=1710http://www.bestbets.org/bets/bet.php?id=1710http://www.bestbets.org/bets/bet.php?id=1710https://www.ncbi.nlm.nih.gov/pubmed/14656957https://en.wikipedia.org/wiki/PubMed_Identifierhttps://dx.doi.org/10.1161%252F01.HYP.0000107251.49515.c2https://en.wikipedia.org/wiki/Digital_object_identifierhttps://en.wikipedia.org/wiki/Hypertensionhttp://hyper.ahajournals.org/cgi/content/abstract/42/6/1206http://hyper.ahajournals.org/cgi/content/abstract/42/6/1206http://hyper.ahajournals.org/cgi/content/abstract/42/6/1206http://www.merck.com/mmhe/sec03/ch023/ch023d.htmlhttp://www.merck.com/mmhe/sec03/ch023/ch023d.htmlhttps://www.ncbi.nlm.nih.gov/pubmed/16087999https://en.wikipedia.org/wiki/PubMed_Identifierhttp://chemistry.about.com/od/factsstructures/a/theobromine-chemistry.htmhttps://www.ncbi.nlm.nih.gov/pubmed/21839757https://en.wikipedia.org/wiki/PubMed_Identifierhttps://dx.doi.org/10.1016%252Fj.physbeh.2011.07.027https://en.wikipedia.org/wiki/Digital_object_identifierhttps://www.ncbi.nlm.nih.gov/pubmed/22096316https://en.wikipedia.org/wiki/PubMed_Identifierhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210006https://en.wikipedia.org/wiki/PubMed_Centralhttps://dx.doi.org/10.4103%252F0973-7847.79097https://dx.doi.org/10.4103%252F0973-7847.79097https://en.wikipedia.org/wiki/Digital_object_identifierhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210006https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210006https://en.wikipedia.org/wiki/National_Institutes_of_Healthhttps://www.nhlbi.nih.gov/health/health-topics/topics/hyp/signs.htmlhttp://www.bupa.co.uk/individuals/health-information/directory/l/low-blood-pressurehttps://en.wikipedia.org/wiki/Help:CS1_errors#first_missing_lasthttp://www.mayoclinic.com/health/low-blood-pressure/DS00590/DSECTION=causeshttps://en.wikipedia.org/wiki/Help:CS1_errors#first_missing_lasthttp://www.mayoclinic.com/health/low-blood-pressure/DS00590http://www.nhlbi.nih.gov/health/dci/Diseases/hyp/hyp_whatis.htmlhttp://www.thefreedictionary.com/hypotensionhttps://en.wikipedia.org/wiki/Orthostatic_intolerancehttps://en.wikipedia.org/wiki/Hypotensive_transfusion_reactionhttps://en.wikipedia.org/wiki/Dysautonomiahttps://en.wikipedia.org/wiki/Ileushttps://en.wikipedia.org/wiki/Adrenal_insufficiencyhttps://en.wikipedia.org/wiki/Adrenal_insufficiencyhttps://en.wikipedia.org/wiki/Steroidshttps://en.wikipedia.org/wiki/Vasopressorhttps://en.wikipedia.org/wiki/Iv_colloid


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4 9 EXTERNAL LINKS

9 External links

Understanding Low Blood Pressure the BasicsWebMD

Hypotension PubMed Health
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004536/https://en.wikipedia.org/wiki/WebMDhttp://www.webmd.com/heart/understanding-low-blood-pressure-basics


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