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Saturday, May 19, 2007

Low Blood Pressure

Also called: Hypotension, LBP

You've probably heard that high blood pressure is a problem. So what about low blood pressure?

Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps out blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure. When your heart is at rest, between beats, your blood pressure falls. This is the diastolic pressure. Your blood pressure reading uses these two numbers. Both are important. Usually they're written one above or before the other, such as 120/80. If your blood pressure reading is 90/60 or lower, you have low blood pressure.

Some people have low blood pressure all the time. They have no symptoms and their low readings are normal for them. In other people, blood pressure drops below normal because of some event or medical condition. Some people may experience symptoms of low pressure when standing up too quickly. Low blood pressure is a problem only if it causes dizziness, fainting or in extreme cases, shock.

National Heart, Lung, and Blood Institute

What Is Blood Pressure?

Blood is carried from the heart to all parts of your body in vessels called arteries. Blood pressure is the force of the blood pushing against the walls of the arteries. Each time the heart beats (about 60–70 times a minute in adults at rest), it pumps blood out into the arteries. Your blood pressure is at its highest when the heart beats, pumping the blood. This is called systolic (sis-TOL-ik) pressure. When the heart is at rest, between beats, your blood pressure falls. This is the diastolic (di-a-STOL-ik) pressure.

Blood pressure is always given as these two numbers, the systolic and diastolic pressures. Both are important. Usually they are written one above or before the other, such as 120/80 mmHg. When the two measurements are written down, the systolic pressure is the first or top number, and the diastolic pressure is the second or bottom number (for example, 120/80). If your blood pressure is 120/80, you say that it is “120 over 80.”

Blood pressure changes during the day. It lowers as you sleep and rises when you wake up. It also can rise when you are excited, nervous, or active.

The body is very sensitive to changes in blood pressure. Special cells in the arteries, called baroreceptors (BAR-o-re-SEP-ters), can sense if blood pressure begins to rise or drop. When the baroreceptors sense a rise or drop in blood pressure, they cause certain responses to occur throughout the body in an attempt to bring the blood pressure back to normal.

For example, if you stand up quickly, the baroreceptors will sense a drop in your blood pressure. They quickly take action to make sure that blood continues to flow to the brain, kidneys, and other important organs. The baroreceptors cause the heart to beat faster and harder. They also cause the small arteries (arterioles) and veins (the vessels that carry blood back to the heart) to narrow.

Most forms of hypotension happen when the body can’t bring blood pressure back to normal or can’t do it fast enough.

Types of Hypotension

There are several types of hypotension. One type, chronic asymptomatic hypotension, happens in people who always have low blood pressure. They have no symptoms and need no treatment. Their low blood pressure is normal for them.

Other types of hypotension happen only sometimes, when blood pressure suddenly drops too low. The symptoms and effects on the body can be mild or severe. The three main types of this kind of hypotension are orthostatic hypotension, neurally mediated hypotension (NMH), and severe hypotension associated with shock.

Orthostatic Hypotension

Orthostatic hypotension is low blood pressure that occurs upon standing up from a sitting or lying down position. It can cause a person to feel dizzy, lightheaded or even to faint. It occurs when the body is not able to adjust blood pressure and blood flow fast enough for the change in position. Usually orthostatic hypotension lasts for only a few seconds or minutes after a person stands up. Sometimes a person will need to sit or lie down for a short time while the blood pressure returns to normal.

Orthostatic hypotension can occur in all age groups, but it is more common in older adults, especially those who are frail or in poor health. Orthostatic hypotension can be a symptom of other medical conditions, and treatment generally focuses on treating the underlying condition(s). Some people can have orthostatic hypotension but also have high blood pressure when lying down.

A form of orthostatic hypotension called postprandial hypotension is a sudden drop in blood pressure after a meal. Postprandial hypotension most commonly affects older adults. It also is more likely to affect those with high blood pressure or diseases such as Parkinson disease.

Neurally Mediated Hypotension

In this form of hypotension, blood pressure drops after a person has been standing for a long time. A person may feel dizzy, faint, or sick to the stomach as a result. NMH also can happen when a person faces an unpleasant, upsetting, or frightening situation.

NMH affects children and young adults more often than other age groups. Children often outgrow this form of hypotension.

Severe Hypotension Associated With Shock

Many times people will say a person has “gone into shock” as a result of an emotionally upsetting experience. But to doctors, the word “shock” has a different meaning. Shock is a life-threatening condition in which blood pressure drops so low that the brain, kidneys, and other vital organs can’t get enough blood to work properly. It is different from the other forms of hypotension because blood pressure drops much lower, and it is life threatening if not treated immediately. There are many causes of shock, including major loss of blood, certain severe types of infection, severe burns, severe allergic reactions, and poisoning

What Causes Hypotension?

Hypotension is caused by conditions or events that interfere with the body’s ability to control blood pressure.
Orthostatic Hypotension
Orthostatic hypotension has many causes. Sometimes, two or more causes combined will result in hypotension.
Dehydration is the most common cause of orthostatic hypotension. Dehydration occurs when the body loses more water than it takes in. People can become dehydrated because of:

* Not drinking enough fluids
* Fever
* Vomiting
* Severe diarrhea
* Excessive sweating from strenuous exercise

Some medicines used to treat high blood pressure and heart disease can make it more likely that a person will develop orthostatic hypotension. These medicines include:

* Diuretics
* Calcium channel blockers
* Angiotensin-converting enzyme (ACE) inhibitors
* Angiotensin II receptor blockers
* Nitrates
* Beta blockers

Also, medicines used to treat certain other medical conditions, such as anxiety, depression, erectile dysfunction, and Parkinson disease, can make it more likely that a person will develop orthostatic hypotension.

Other substances that can contribute to orthostatic hypotension include alcohol, barbiturates, and some prescription and over-the-counter medicines, when taken in combination with high blood pressure medicines.

Certain medical conditions can increase a person's chances of having orthostatic hypotension. Some of these conditions are:

* Anemia (low red blood cell count).
* Heart conditions leading to heart failure, such as a heart attack or viral infection of the heart. These conditions reduce the heart’s ability to pump enough blood around the body.
* Heart valve disorders.
* Severe infections.
* Endocrine conditions, such as hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), Addison’s disease (adrenal insufficiency), low blood sugar, and diabetes.
* Disorders of the central nervous system, such as Parkinson disease, multiple systems atrophy (Shy-Drager syndrome), and amyloidosis.
* Pulmonary embolism (a sudden blockage in a lung artery).

Finally, other events or conditions that can contribute to orthostatic hypotension include:

* Being out in the heat for a long time
* Having to stay in bed for a long time because of a medical condition
* Being pregnant
* Getting older (the body doesn’t manage changes in blood pressure as well as it gets older)

Neurally Mediated Hypotension

Neurally mediated hypotension (NMH) occurs when the brain and heart don’t communicate with each other properly. For example, when a person stands for a long time, blood begins to pool in the legs. This causes the person’s blood pressure to drop. Instead of telling the brain that blood pressure is low, the body mistakenly tells the brain that blood pressure is high. In response, the brain slows the person’s heart rate, which makes the blood pressure drop even further, causing dizziness and other symptoms.
Severe Hypotension Associated With Shock

Severe hypotension associated with shock can be caused by many conditions or events. Some of these conditions and events also are causes of orthostatic hypotension. The difference in shock is that the blood pressure doesn’t return to normal by itself, and it is at dangerously low levels. Shock is a medical emergency that must be treated immediately.

Certain severe infections can cause shock. This is known as septic shock. This type of shock can occur when bacteria enter the bloodstream. The bacteria release a toxin (a poison) that leads to a dangerous drop in blood pressure.

Shock can be caused by a severe decrease in the amount of blood or fluids in the body. This is known as hypovolemic shock. Hypovolemic shock can happen as a result of:

* Major bleeding on the outside of the body (for example, from an injury)
* Major bleeding inside the body (for example, from a ruptured blood vessel)
* Significant loss of body fluids from severe burns
* Severe inflammation of the pancreas
* Severe diarrhea
* Severe kidney disease
* Excessive use of diuretics

A major decrease in the heart’s ability to pump blood can cause shock. This is known as cardiogenic shock. It can be caused by a heart attack, pulmonary embolism, or arrhythmia.

A sudden and extreme relaxation of the muscles of arteries, which leads to dilation (widening) of the arteries and a drop in blood pressure, can cause shock. This is known as vasodilatory shock. It can happen because of:

* Severe head injury
* Reaction to some medicines
* Liver failure
* Poisoning
* Severe allergic reaction (anaphylactic shock)

Who Is At Risk for Hypotension?

People of all ages can have hypotension, though people of certain ages are more likely to have certain kinds:

* Older adults are more likely to have orthostatic and postprandial hypotension.
* Children and young adults are more likely to have neurally mediated hypotension.

People who take certain medicines, such as high blood pressure medicines, have a higher risk of hypotension.

People with Parkinson disease and some heart conditions also have a higher risk of hypotension.

What Are the Signs and Symptoms of Hypotension?
Orthostatic Hypotension

The symptoms of orthostatic hypotension happen within a few seconds or minutes of a person standing up after sitting or lying down. They go away if the person sits or lies down again. The signs and symptoms include:

* Dizziness or feeling lightheaded
* Blurry vision
* Confusion
* Feeling faint or weak
* Fainting

Neurally Mediated Hypotension

The symptoms of neurally mediated hypotension (NMH) happen after a person has been standing for a long time or in response to an unpleasant, upsetting, or frightening situation. Like orthostatic hypotension, the drop in blood pressure with NMH is temporary and usually goes away after the person sits down. The signs and symptoms of NMH are similar to those of orthostatic hypotension.
Severe Hypotension Associated With Shock

In shock, not enough blood flows to the major organs, including the brain.

The early signs and symptoms of reduced blood flow to the brain include lightheadedness, sleepiness, and confusion. In the earliest stages of shock, it may be hard to detect any signs and symptoms. In older people, the first symptom may only be confusion.

As shock worsens, eventually, the person cannot sit up without passing out. If it continues, the person will lose consciousness. Shock is often fatal if not treated.

Some of the other signs and symptoms of shock vary, depending on the cause. When shock is caused by low blood volume (such as from massive bleeding) or poor pumping action by the heart (as in heart failure):

* The skin becomes cold and sweaty. It often looks blue or pale. If pressed, the color returns more slowly than normal. A bluish network of lines can be seen under the skin.
* The pulse becomes weak and rapid.
* The person begins to breathe very quickly.

When shock is caused by extreme widening or stretching of blood vessels (such as in septic shock), a person feels warm and flushed at first. Later, the skin becomes cold and clammy, and the person feels very sleepy.

How Is Hypotension Treated?

Treatment depends on the cause of the hypotension and how severe the signs and symptoms are.

Hypotension in a healthy person that does not cause signs or symptoms usually does not need to be treated. Hypotension that causes signs or symptoms often needs to be treated. Severe hypotension associated with shock is a medical emergency. It can cause death if it is not treated immediately.

A person’s response to treatment depends on his or her age and overall health and strength. It also depends on how easily the person can stop, start, or change medicines.

Any person with blood pressure low enough to cause symptoms should immediately sit or lie down, with the feet up above the level of the heart. Low blood pressure symptoms that do not go away very quickly upon sitting or lying down can be a medical emergency, and immediate medical attention is needed.
Treating Orthostatic Hypotension

The goals of treatment are to relieve or improve signs and symptoms and to manage any underlying medical condition causing the hypotension.

Treatment can include:

* Making lifestyle changes, such as:
o Drinking plenty of fluids, like water
o Drinking little or no alcohol
o Standing up slowly
o Gradually sitting up for longer periods of time if you’ve had to stay in bed for a long time
* Using compression stockings that apply pressure to the lower body. These garments drive blood from the legs to the heart and brain and help blood circulate through the body.
* Stopping a medicine or changing the dose if the medicine is causing the hypotension.
* Taking medicine to raise blood pressure, reduce signs and symptoms, and treat related conditions. Medicines include ephedrine, phenylephrine, fludrocortisone, beta blockers, and nonsteroidal anti-inflammatory medicines.

Treating Neurally Mediated Hypotension

Treatment for neurally mediated hypotension (NMH) can include:

* Making lifestyle changes, such as:
o Avoiding situations that trigger symptoms. For example, don’t stand for long periods of time, and avoid frightening or upsetting situations.
o Drinking plenty of fluids, like water.
o Increasing salt intake.
o Learning to recognize symptoms that occur before fainting, and taking action to raise blood pressure (crossing the legs and squeezing them together or lying down).
* Stopping a medicine or changing the dose if the medicine is causing the hypotension.
* Taking medicines, such as fludrocortisone, to treat the hypotension if symptoms are very bad.

Children with NHM often outgrow it.
Treating Severe Hypotension Associated With Shock

Shock is a life-threatening emergency that usually requires treatment in a hospital or by emergency medical personnel. The goals of treating shock are to restore blood flow to the organs as quickly as possible, to prevent organ damage, and to find and reverse the cause of the shock.

Restoring blood flow to the organs often requires that special fluids or blood be given directly into the bloodstream through a needle. Medicines can be given to raise the blood pressure or make the heartbeat stronger. Depending on the cause of the shock, other treatments such as antibiotics or surgery may be required.


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