Transcript Syncope and Hypotension in the Elderly Patient

Syncope and Hypotension
in the Elderly Patient
Lewis A. Lipsitz, MD
Hebrew SeniorLife,
Beth Israel Deaconess Medical Center,
Harvard Medical School
Disclosures: None
Syncope Definition
Transient loss of consciousness,
characterized by unresponsiveness and
loss of postural tone, with spontaneous
recovery.
Epidemiology of Syncope
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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 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 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 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 NH
Diseases
Myocardial Infarction
Aortic Stenosis
Dehydration
Seizure Disorder
Cerebrovascular Event
Cardiac Ischemia
Tachy-Brady Syndrome
Lipsitz, LA, J Chronic Ds, 1986; 39:619
No. of Patients
6
5
4
3
3
3
3
Etiology 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 - 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
Etiology of Syncope - 4
Unknown
No identifiable precipitants
Unexplained hypotension
No. of Patients
17
8
Elderly patients are at risk of
hypotension during common
daily activities.
Age-related Changes in BP Regulation
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Decreased cerebral blood flow
Baroreflex impairment
Reduced renal salt and water conservation
Impaired early diastolic ventricular filling
190
SUP
STD
BREAK
STD/AMB
NTG STD AMB
MED LUNCH
STD
SBP (mm Hg)
170
150
old
130
young
110
90
7
8
9
10
Time (hours)
11
12
1
The Higher You Are, The Farther
You Fall
Honolulu Heart Study
Prevalence of OH*
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
71-74
75-79
Masaki, Circulation 1998;98:2290
80-84
Age
85+
* 3 min stdg
Prevalence of OH by Age
Age
N
55-59
621
% with >20
mmHg drop
11.6
60-64
1,617
10.6
65-69
1,288
12.2
70-74
982
15.9
Prevalence of OH by
Level of Supine SBP
Supine SBP
N
<120
567
% with >20
mmHg drop
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
Age
N
55-59
99
% with > 20
mmHg drop
28.3
60-64
309
24.6
65-69
312
26.3
70-74
310
28.4
Effect of Hypotension on the Brain
Role of Medications in
Hypotension and Syncope?
The effect of HCTZ
and mild volume
contraction on BP
response to tilt in
healthy young and
elderly subjects.
Shannon RP, et al,
Hypertension 8:438, 1986
Orthostatic Hypotension is Reduced By
Chronic Antihypertensive Therapy
Baseline
mo
t
No
r
22
20
22
18
18
10*
4 4
0
0
0
e..
Ni
fed .
ipi
M
eto ne
pr
olo
En
l
ala
pr
il
Pr
az
os
in
Th
iaz
ide
25
Prevalence 20
15
(%) of
Orthostatic 10
Hypotension 5
0
2 Years
Masuo et al. AJH 1996; 9:
6*
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
Lipsitz, et. al., Hypertension, 2005
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 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 - Labs
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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))
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
• 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 OH
• Systemic
– Hypertension
– Dehydration
– Deconditioning
– Adrenocortical
insufficiency
• Drugs
– Antipsychotics
– MAOs & tricyclics
– antihypertensives
(acute doses)
– vasodilators (NTG)
– L-Dopa
– BBs, CCB’s, etc.
Causes of OH
• Autonomic Neuropathy
• CNS Disorders
– Diabetes Mellitus
– Multiple Systems
Atrophy
– Amyloidosis
– Parkinson’s Disease
– Tabes Dorsalis
– Multiple Strokes
– Paraneoplastic
– Myelopathy
– Alcohol
– Brain stem lesions
– Nutritional
Evaluation 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 OH
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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 PPH
20 mm Hg or greater decline
in systolic BP within 2 hours
of the start of a meal.
PPH - 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 PPH
• BP pre & post meal: 400 kcal, 7080% 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 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.
Mean Arterial Pressure (mmHg)
110
100
90
80
Walk
-5
0
5
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Time after meal (min)
Nach dem essen sollst du ruhen
oder tausand schritte tuen.
-German folk wisdom
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 mg subQ, 30 min. pre-meals
Challenges 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 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.