Title: Syncope and Hypotension in the Elderly Patient
1Syncope and Hypotensionin the Elderly Patient
- Lewis A. Lipsitz, MD
- Hebrew SeniorLife,
- Beth Israel Deaconess Medical Center,
- Harvard Medical School
Disclosures None
2Syncope Definition
- Transient loss of consciousness, characterized
by unresponsiveness and loss of postural tone,
with spontaneous recovery.
3Epidemiology 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.
4Syncope 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.
5Syncope 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.
6Syncope 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
7Etiology 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 39619
8Etiology 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
9Etiology of Syncope - 3
- Situational 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
10Etiology of Syncope - 4
- Unknown No. of Patients
- No identifiable precipitants 17
- Unexplained hypotension 8
11Elderly patients are at risk of hypotension
during common daily activities.
12Age-related Changes in BP Regulation
- Decreased cerebral blood flow
- Baroreflex impairment
- Reduced renal salt and water conservation
- Impaired early diastolic ventricular filling
13Aging, Hypertension, and BP Regulation
Aging
BP Elevation
Impaired BP Regulation
Hypotension
Cerebral Hypoperfusion
14 Blood Pressure Equation
15Cardiovagal baroreflex gain declines with age.
Gribbin et al. Circ. Research, 29426, 1971
16Age-related Changes in Plasma Norepinephrine
17Aged-related Increase in Sympathetic Response to
Orthostatic Stress
Davy et al, HTN 1998
18Age-related Decrease in Vascular Response to
Sympathetic Activity
Davy et al, HTN 1998
19Reduced Salt and Water Conservation
Adapted from Epstein, et al, Fed Proc 1979 170.
20Age-related Change in Plasma Renin Activity
21Diastolic Dysfunction
A
A
Normal transmitral Doppler ventricular inflow
pattern
Reduced early, increased late diastolic
ventric.filling
22190
SUP
STD
BREAK
STD/AMB
NTG
STD
AMB
MED
LUNCH
STD
170
150
SBP (mm Hg)
old
130
young
110
90
9
7
8
10
11
12
1
Time (hours)
23(No Transcript)
24(No Transcript)
25The Higher You Are, The Farther You Fall
26Honolulu Heart Study Prevalence of OH
Age
3 min stdg
Masaki, Circulation 1998982290
27Prevalence of OH by Age
28Prevalence of OH byLevel of Supine SBP
29Prevalence of OH by Age if Supine SBP gt 160 mmHg
30Effect of Hypotension on the Brain
31Role of Medications in Hypotension and Syncope?
32The effect of HCTZ and mild volume contraction
on BP response to tilt in healthy young
and elderly subjects.
Shannon RP, et al, Hypertension 8438, 1986
33Orthostatic Hypotension is Reduced By Chronic
Antihypertensive Therapy
Masuo et al. AJH 1996 9 263-8
34(No Transcript)
35(No Transcript)
36Does 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.
37Effect of 6 Months of BP Control on Cerebral
Blood Flow
Lipsitz, et. al., Hypertension, 2005
38(No Transcript)
39Whats Different About Syncope in Elderly People?
- Multiple Pathologic Conditions
- Situational Hypotension
- Postprandial
- Drug-induced
- Orthostatic
- Cardiovascular causes gt vasovagal
- Vasovagal prodrome is less common.
- Reflex Syncope - e.g. Carotid Sinus Synd.
40Syncope 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
41Syncope 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
42Whom 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 lt 30 and - 8) Primary CNS event.
43Definition 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.
44Causes of OH
- Systemic
- Hypertension
- Dehydration
- Deconditioning
- Adrenocortical insufficiency
- Drugs
- Antipsychotics
- MAOs tricyclics
- antihypertensives (acute doses)
- vasodilators (NTG)
- L-Dopa
- BBs, CCBs, etc.
45Causes of OH
- Autonomic Neuropathy
- Diabetes Mellitus
- Amyloidosis
- Tabes Dorsalis
- Paraneoplastic
- Alcohol
- Nutritional
- CNS Disorders
- Multiple Systems Atrophy
- Parkinsons Disease
- Multiple Strokes
- Myelopathy
- Brain stem lesions
46Evaluation 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.
47Nonpharmacologic 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
48Definition of PPH
- 20 mm Hg or greater decline in systolic BP
within 2 hours of the start of a meal.
49PPH - Clinical Associations
- Patients with HTN, autonomic insufficiency,
Parkinsons 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, TIAs, lacunar infarcts, leukoaraiosis
50Evaluation of PPH
- BP pre post meal 400 kcal, 70-80 CHO.
- Hx Meds, EtOH, autonomic Sx, HTN, DM, CVD,
Parkinsons, autonomic neuropathy. - post-meal EKG to r/o angina.
- consider dumping syndrome.
51Nonpharmacologic 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.
52Walk
53Nach dem essen sollst du ruhenoder tausand
schritte tuen.
54Pharmacologic 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 mg subQ, 30 min. pre-meals
55Challenges 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.
56Principles 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.