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

The Higher You Are, The Farther You Fall

The Higher You Are, The Farther You Fall

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

Effect of Hypotension on the BrainEffect of Hypotension on the Brain

Role of Medications in Hypotension and Syncope?

Role of Medications in Hypotension and Syncope?

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.