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08/16/2011 - orthostatic hypotension

posted Sep 28, 2011, 5:11 PM by Chief Resident   [ updated Sep 28, 2011, 5:13 PM by Purnema Madahar ]
IPRO are in the hospital and either have talked to you already or will in the next few days. But who are they? According to their website (www.ipro.org), they are a not-for-profit organization with the exotic name Island Peer Review Organization who have been under contract with the New York State Department of Health (NYSDOH) since 2001 to monitor post-graduate trainee work hours in New York. The goal is to strengthen patient safety and quality assurance practices in hospitals statewide.

They are different from the ACGME and are not responsible for accreditation of the residency program. Instead, they have fined hospitals in the past for violations of work hour rules.

Intake this morning prompted a discussion about orthostatic hypotension that warrants some follow up:

According to the Consensus Committee of the American Autonomic Society and the American Academy of Neurology (attached), orthostatic hypotension (OH) is defined as a reduction in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing.

Besides this â classicâ orthostatic hypotension, at least two variants have been characterized:

1. Initial orthostatic hypotension (IOH) is defined as a transient BP decrease within 15 s after standing, > 40 mmHg SBP (systolic BP) and/or > 20 mmHg DBP (diastolic BP) with symptoms of cerebral hypoperfusion. The attached paper discusses the potential physiology.

2. Delayed orthostatic hypotension is defined as OH beyond 3 minutes. In the attached study, delayed OH was found in about 50% of 230 patients referred to a dedicated tilt-table lab at a tertiary medical center.

Amit Patel pointed out an interesting paper that was reviewed in Journal Watch (http://general-medicine.jwatch.org/cgi/content/full/2011/428/1) which looked at OH in elderly, community dwelling, asymptomatic participants. It found initial OH (within 15 seconds!) in 85/443 participants, which was significantly associated with recent falls and frailty.

To drive home the importance of checking orthostatics in patients who present with (near) syncope and the need to tailor your workup, check out the attached paper on the yield of diagnostic tests in syncope of the elderly. Some results of this chart review of 2100 patients that presented with syncope:

1. Orthostatics were only checked in 38% of presentations, as compared to EKG 99%, cardiac enzymes 95%, head CT 63%.
2. Orthostatics affected diagnosis in about 25% of cases in which they were obtained, versus 2-7% for the other tests.
3. The costs are tremendous: cost per test that affected management were $7 for orthostatics but $24,000 for head CTs!

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