Post on 16-Dec-2015
Syncope and Hypotensionin the Elderly Patient
Syncope and Hypotensionin the Elderly Patient
Lewis A. Lipsitz, MD
Hebrew SeniorLife,
Beth Israel Deaconess Medical Center,
Harvard Medical School
Disclosures: None
Syncope DefinitionSyncope Definition
Transient loss of consciousness, characterized by unresponsiveness and loss of postural tone, with spontaneous recovery.
Epidemiology of SyncopeEpidemiology of Syncope
• Prevalence up to 47% in healthy young
• 23% 10-year pevalence in the NH pop.
• 6-33% 1-year mortality in pts. over 60.
• $2 Billion annual costs.
• Up to 40% of cases remain unexplained, despite extensive inpatient evaluations.
Syncope Case 1Syncope Case 1
• An 88 year old nursing home resident with hypertension, CAD, and mild dementia was found unresponsive and slumped in her chair, 1 hour after breakfast. She had taken isosorbide dinitrate, metoprolol, lisinopril, and HCTZ before breakfast. Her BP was 105/72, pulse was 64.
Syncope Case 2Syncope Case 2
• An active 75 y.o. man with no active medical problems suddenly became dizzy and fainted while cleaning his apartment. A friend found him and rushed him to the hospital where he was admitted and ruled out for an MI. A head CT and exercise stress test were normal. BP and P were: 158/92, 72 supine and 90/62, 72 standing.
Syncope EtiologySyncope Etiology
Only if one knows the causes of syncope will he be able to recognize its onset and combat the cause.
Miamonides
1135-1204 CE
Etiology of Syncope in the NHEtiology of Syncope in the NH
Diseases No. of Patients
Myocardial Infarction 6
Aortic Stenosis 5
Dehydration 4
Seizure Disorder 3
Cerebrovascular Event 3
Cardiac Ischemia 3
Tachy-Brady Syndrome 3
Lipsitz, LA, J Chronic Ds, 1986; 39:619
Etiology of Syncope - 2Etiology of Syncope - 2
Diseases No. of Patients
Acute respiratory failure 2
Cervical Spondylosis 1
Sinus arrest 1
Paroxysmal atrial tachycardia 1
Carotid sinus syndrome 1
Heart block 1
Etiology of Syncope - 3Etiology of Syncope - 3Situational Stresses No. of Patients
Drug-induced hypotension 11
Postprandial hypotension 8
Defecation/colostomy irrigation 7
Orthostatic hypotension 6
Fecal impaction 3
Vomiting 1
Micturition 1
Bending over 1
Etiology of Syncope - 4Etiology of Syncope - 4
Unknown No. of Patients
No identifiable precipitants 17
Unexplained hypotension 8
Elderly patients are at risk of hypotension during common
daily activities.
Elderly patients are at risk of hypotension during common
daily activities.
Age-related Changes in BP RegulationAge-related Changes in BP Regulation
• Decreased cerebral blood flow
• Baroreflex impairment
• Reduced renal salt and water conservation
• Impaired early diastolic ventricular filling
190
170
150
130
110
90
SUP STD BREAK STD/AMB NTG STD AMB MED LUNCH STD
7 8 9 10 11 12 1
Time (hours)
SB
P (
mm
Hg)
old
young
Honolulu Heart Study Prevalence of OH*
Honolulu Heart Study Prevalence of OH*
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
71-74 75-79 80-84 85+
AgeMasaki, Circulation 1998;98:2290 * 3 min stdg
Prevalence of OH by AgePrevalence of OH by Age
Age N % with >20 mmHg drop
55-59 621 11.6
60-64 1,617 10.6
65-69 1,288 12.2
70-74 982 15.9
Prevalence of OH byLevel of Supine SBPPrevalence of OH byLevel of Supine SBP
Supine SBP N % with >20 mmHg drop
<120 567 2.8
120-139 1,549 5.2
140-159 1,362 13.6
>160 1,030 26.6
Prevalence of OH by Age if Supine SBP > 160 mmHg
Prevalence of OH by Age if Supine SBP > 160 mmHg
Age N % with > 20 mmHg drop
55-59 99 28.3
60-64 309 24.6
65-69 312 26.3
70-74 310 28.4
The effect of HCTZ and mild volume contraction on BP response to tilt in healthy young andelderly subjects.
Shannon RP, et al,Hypertension 8:438, 1986
Orthostatic Hypotension is Reduced By Chronic Antihypertensive Therapy
Orthostatic Hypotension is Reduced By Chronic Antihypertensive Therapy
Masuo et al. AJH 1996; 9: 263-8
4 4
22
0
20
0
18
0
18
10*
22
6*05
10152025
Prevalence (%) of
Orthostatic Hypotension
Baseline 2 Years
Does Antihypertensive Therapy Threaten Cerebral Blood Flow?
Does Antihypertensive Therapy Threaten Cerebral Blood Flow?
Sit-to-stand Procedure• Avoids hydrostatic
changes in perfusion pressure (vs. tilt).
• Simulates a common activity of daily living.
• Causes rapid and reproducable declines in arterial pressure.
Effect of 6 Months of BP Control on Cerebral Blood Flow
Effect of 6 Months of BP Control on Cerebral Blood Flow
Lipsitz, et. al., Hypertension, 2005
What’s Different About Syncope in Elderly People?
What’s Different About Syncope in Elderly People?
• Multiple Pathologic Conditions
• Situational Hypotension– Postprandial– Drug-induced– Orthostatic
• Cardiovascular causes > vasovagal
• Vasovagal prodrome is less common.
• Reflex Syncope - e.g. Carotid Sinus Synd.
Syncope EvaluationSyncope Evaluation
• Hx of diseases, drugs, and precipitants
• PE for CV ds., neuro signs, GI bleeding
• BP during activities preceding syncope: posture change, meals & medications.
• Carotid sinus massage (if no CVD or cardiac conduction disease)
• Focused laboratory studies
Syncope Evaluation - LabsSyncope Evaluation - Labs
• For most patients: EKG, Chem screen, CBC.
• If cardiac sx, or abnormal EKG - r/o MI
• If Hx of CVD - ambulatory cardiac monitor
• If situational - ambulatory BP monitoring
• If suspicious murmur - cardiac echo/Doppler
• If focal neuro findings or Seizures - EEG/CT
• If unexplained - Tilt and EPS
Whom to Admit? Boston Syncope Rule (97% Sens., 62% Spec. for adverse outcome or
critical intervention (Grossman, JEM 2007))
Whom to Admit? Boston Syncope Rule (97% Sens., 62% Spec. for adverse outcome or
critical intervention (Grossman, JEM 2007))
1) Signs and sx of an acute coronary syndrome;
2) Signs of conduction disease;
3) Worrisome cardiac history;
4) Valvular heart disease by history or physical;
5) Family history of sudden death;
6) Persistent abnormal vital signs in the ED;
7) Volume depletion such as persistent dehydration, GI bleeding, or hematocrit < 30; and
8) Primary CNS event.
Definition of Orthostatic Hypotension
Definition of Orthostatic Hypotension
• 20 mmHg or greater decline in systolic BP and/or 10 mmHg or greater decline in diastolic BP when changing from a supine to upright position (sitting or standing).
• 1 and/or 3 minute value.
• HR is not a reliable indicator in geriatric patients because of baroreflex impairment.
Causes of OHCauses of OH
• Systemic– Hypertension– Dehydration– Deconditioning– Adrenocortical
insufficiency
• Drugs– Antipsychotics– MAOs & tricyclics – antihypertensives
(acute doses)– vasodilators (NTG)– L-Dopa – BBs, CCB’s, etc.
Causes of OHCauses of OH
• CNS Disorders– Multiple Systems
Atrophy– Parkinson’s Disease– Multiple Strokes– Myelopathy– Brain stem lesions
• Autonomic Neuropathy– Diabetes Mellitus– Amyloidosis– Tabes Dorsalis– Paraneoplastic– Alcohol– Nutritional
Evaluation of OHEvaluation of OH
• Sx: Postural dizziness, falls, or syncope; po intake; abnl. sweating, incontinence, HA,GI dysmotility, impotence, poor night vision.
• Hx: HTN, DM, CA, Stroke, Parkinsons, Arrhythmias, Meds & alcohol.
• PE: BP & P supine, 1 & 3 min stdg; pupils, skin, CV and neuro exams.
• Labs: Hct, Lytes, Glu, SPEP, B12, RPR +/- cortisol, brain imaging, tilt with NE levels, HRV during deep breathing & Valsalva, sweat tests.
Nonpharmacologic RX of OHNonpharmacologic RX of OH
• Drug withdrawal, substitution or reduction
• Avoid warm environment
• Avoid straining activity
• Squatting, leg crossing
• Increase salt intake
• Waist-high compression stockings
• Sleeping in the head-up position
Definition of PPHDefinition of PPH
20 mm Hg or greater decline in systolic BP within 2 hours of the start of a meal.
PPH - Clinical AssociationsPPH - Clinical Associations
• Patients with HTN, autonomic insufficiency, Parkinson’s Disease, Diabetes, Renal failure
• 24-36% of nursing home residents.
• 23% of elderly patients admitted to a geriatric hospital with syncope or falls.
• 50% of elderly pts. with unexplained syncope
• Angina, TIA’s, lacunar infarcts, leukoaraiosis
Evaluation of PPHEvaluation of PPH
• BP pre & post meal: 400 kcal, 70-80% CHO.
• Hx: Meds, EtOH, autonomic Sx, HTN, DM, CVD, Parkinson’s, autonomic neuropathy.
• post-meal EKG to r/o angina.
• consider dumping syndrome.
Nonpharmacologic Rx of PPHNonpharmacologic Rx of PPH
• Stop hypotensive meds or give between meals.
• Avoid preload reduction (diuretics or prolonged sitting), maintain adequate intravascular vol.
• Avoid EtOH.
• Multiple small meals of protein and fat.
• Walking exercise after meals (frail elderly).
• ? cold rather than warm meals.
Time after meal (min)-5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Me
an
Art
eri
al P
res
su
re (m
mH
g)
80
90
100
110
Time after meal (min)-5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Me
an
Art
eri
al P
res
su
re (m
mH
g)
80
90
100
110
Walk
Nach dem essen sollst du ruhenoder tausand schritte tuen.
Nach dem essen sollst du ruhenoder tausand schritte tuen.
-German folk wisdom
Pharmacologic Rx of OH and PPH
Pharmacologic Rx of OH and PPH
• Caffeine: 250 mg (2 cups brewed) in AM
• Fludrocortisone: 0.1 to 1.0 mg QD (watch for CHF, supine HTN, and hypokalemia.
• Midodrine: 2.5-10 mg po TID (supine HTN)
• Octreotide: 50 g subQ, 30 min. pre-meals
Challenges and Unmet NeedsChallenges and Unmet Needs
1. Causes of Unexplained Syncope?– Neurally-mediated (vasovagal): fewer premonitory sx in
elderly patients.
– Dysautonomia
– Paroxysmal brady- or tachy-arrhythmias
– Carotid Sinus Hypersensitivity
2. Better Diagnostic tools – Tilt tests, EPS, BP monitoring? Validate Syncope Rule in Elderly
3. Methods to improve cerebral perfusion.
Principles of TreatmentPrinciples of Treatment
• Treat the primary etiology if one is found.
• Age is NOT a contraindication to treatment, but increases the risk of drugs and surgery.
• Identify and minimize the impact of multiple contributors, particularly drugs.
• Behavioral interventions to avoid situational hypotension.