QuestionSBA
QuestionChoice
Aspirin is a COX-1 and COX-2 inhibitor. It does not commonly cause postural hypotension.
62125
c
Aspirin 75mg
QuestionChoice
Fludrocortisone is a mineralocorticoid which is sometimes used to boost blood pressure.
62124
b
Fludrocortisone 50 micrograms
QuestionChoice
Correct. Tamsulosin is an alpha adrenoceptor blocker. It therefore impairs reactive vasocontriction in response to a drop in blood pressure.
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a
Tamsulosin 400micrograms
QuestionChoice
Prednisolone is a steroid which would not cause postural hypotension. Steroids may improve postural hypotension if the cause is mineralocorticoid deficiency (adrenal insufficiency).
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d
Prednisolone 30mg OD
QuestionChoice
This is an anti-spasmodic agent commonly used in treatment of irritable bowel syndrome. It would not commonly cause postural drop.
62127
e
Hyoscine Butylbromide 20mg TDS
QuestionComment
male she/her?
25855
QuestionComment
this comment assumes gender permanence and is transphobic
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User
subscriber
Chronic Wilsons
User
subscriber
Serpiginous Defibrillator
QuestionComment
She / her with BPH alliessss Quesmed 🏳️‍⚧️
26926
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subscriber
Kinase RNA
Concept
Chapter
# Summary

Postural or orthostatic hypotension is a condition characterised by a significant drop in blood pressure upon standing. Key signs and symptoms include dizziness, syncope, falls, fractures, and more frequent occurrences following meals, exercise, and in warm environments. Key investigations involve identifying a fall of 20mmHg or more in systolic blood pressure, or a fall of 10mmHg or more in diastolic pressure. Management strategies largely depend on the cause and can range from ensuring adequate hydration to evaluating polypharmacy to pharmacotherapy.

# Definition

Orthostatic hypotension is characterised by a decrease in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within three minutes of standing when compared with blood pressure from the sitting or supine position.

# Epidemiology

Orthostatic hypotension is common in the elderly population, with approximately 50% of elderly individuals living in residential institutions being affected. 

# Aetiology

The causes of orthostatic hypotension include:

- Medications, particularly vasodilators, diuretics, negative inotropes, antidepressants, and opiates
- Chronic hypertension due to the loss of baroreceptor reflexes
- Dehydration
- Sepsis
- Autonomic nervous system dysfunction, such as Parkinson's disease
- Adrenal insufficiency

# Signs and symptoms

Patients with orthostatic hypotension may present with:

- Dizziness
- Syncope
- Falls
- Fractures
- More frequent occurrences after meals or exercise
- More frequent occurrences in warm environments
- Sometimes precipitated by coughing or defecating
- Symptoms can occur several minutes after standing up

# Differential diagnosis

When diagnosing orthostatic hypotension, it is essential to rule out other conditions that may cause similar symptoms. These can include:

- Vertigo: Characterized by a spinning sensation and loss of balance
- Hypoglycemia: Presents with signs such as shakiness, hunger, confusion, and sweating
- Cardiac arrhythmias: Symptoms may include palpitations, chest pain, and shortness of breath

# Investigations

The diagnosis of orthostatic hypotension is confirmed by a significant fall of 20mmHg or more in systolic blood pressure, or a fall of 10mmHg or more in diastolic pressure upon standing.

# Management

Management of orthostatic hypotension depends on the underlying cause and may include:

- Ensuring adequate hydration
- Evaluating polypharmacy to identify medication-related causes
- Implementing strategies to reduce adverse outcomes from falls (e.g., fall alarm, soft flooring)
- Advising behavioral changes such as rising from sitting slowly, maintaining adequate hydration
- Recommending the use of compression stockings
- Employing pharmacotherapy, including fludrocortisone and midodrine, although the evidence base for fludrocortisone is weak

# References

- [NICE Guideline: Orthostatic hypotension due to autonomic dysfunction: midodrine](https://www.nice.org.uk/advice/esnm61/chapter/)
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Geriatrics
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Quesmed Tutorial: Geriatrics
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A 76 year old male presents to the emergency department after multiple falls. He has a past medical history of irritable bowel syndrome, heart failure, chronic obstructive pulmonary disease and benign prostatic hypertrophy. His heart rate is 76bpm, and his blood pressure is 146/82 on lying and 124/79 upon standing (at 3 minutes). He is euvolaemic on examination.

Which of the following medication is most likely to be responsible for this presentation?
a