What is the next step in managing a patient with suspected orthostatic hypotension and a pacemaker after normal echo and stress test results?

From the Guidelines

The next step in managing a patient with suspected orthostatic hypotension and a pacemaker after normal echo and stress test results should be to perform autonomic function testing, including a formal orthostatic vital sign assessment and possibly tilt table testing. Begin by measuring blood pressure and heart rate while the patient is supine for 5 minutes, then immediately upon standing, and again at 1,3, and 5 minutes after standing. A drop in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg within 3 minutes of standing confirms orthostatic hypotension 1.

Key Considerations

• Review the patient's medications as many drugs can cause or worsen orthostatic hypotension, including antihypertensives, diuretics, alpha-blockers, and certain psychiatric medications.
• Consider adjusting the pacemaker settings if the heart rate response is inadequate during position changes.
• Initial management should focus on non-pharmacological measures such as:
  • Increasing fluid intake (2-2.5 L/day)
  • Adding salt to the diet (8-10g/day)
  • Wearing compression stockings
  • Performing physical countermaneuvers like leg crossing and muscle tensing
• If these measures are insufficient, pharmacological therapy may include midodrine (2.5-10 mg three times daily, with the last dose at least 4 hours before bedtime) or fludrocortisone (0.1-0.3 mg daily), as recommended by guidelines for the treatment of orthostatic hypotension 1.

Pharmacological Therapy

• Midodrine and droxidopa are approved by the FDA for the treatment of orthostatic hypotension 1.
• The therapeutic goal is to minimize postural symptoms rather than to restore normotension, and most patients require both nonpharmacologic and pharmacologic measures 1.

Non-Pharmacological Measures

• Physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance 1.
• Volume repletion with fluids and salt is critical, and supine blood pressure tends to be much higher in these patients, often requiring treatment of blood pressure at bedtime with shorter-acting drugs 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations After initiation of treatment, midodrine hydrochloride tablets should be continued only for patients who report significant symptomatic improvement.

The next step in managing a patient with suspected orthostatic hypotension and a pacemaker after normal echo and stress test results is to consider midodrine therapy if the patient's life is considerably impaired despite standard clinical care. The patient should be evaluated for the potential of supine and sitting hypertension, and blood pressure should be monitored carefully. Additionally, the patient should be advised to report symptoms of supine hypertension immediately and to discontinue the medication if supine hypertension persists. Caution should be exercised when midodrine is used concomitantly with other agents that cause vasoconstriction or cardiac glycosides. 2 2 2

From the Research

Next Steps in Managing Orthostatic Hypotension

Given the normal echo and stress test results, the next steps in managing a patient with suspected orthostatic hypotension and a pacemaker involve:

• Ruling out non-neurogenic causes of orthostatic hypotension, such as medications and cardiac problems 3
• Considering neurogenic orthostatic hypotension, which can accompany parkinsonian diseases and is associated with increased risk of morbidity and mortality 3
• Implementing non-pharmacologic therapies, such as increasing fluid and salt intake, and venous compression methods, as initial treatment 4, 5
• If non-pharmacologic measures fail, introducing pharmacologic interventions, such as fludrocortisone, midodrine, or droxidopa, stepwise depending on the severity of symptoms 3, 4, 6

Pharmacologic Treatment Options

The following pharmacologic treatment options are available for orthostatic hypotension:

• Fludrocortisone, a mineralocorticoid that increases blood volume and blood pressure 4
• Midodrine, an alpha-agonist that improves orthostatic blood pressure by increasing vasomotor and venomotor tone 6
• Droxidopa, a synthetic precursor of norepinephrine that increases blood pressure 3

Monitoring and Management

It is essential to monitor the patient's blood pressure, orthostatic symptoms, and potential side effects of treatment, and adjust the treatment plan as needed 5. Additionally, supine hypertension and postprandial hypotension should be monitored and managed to prevent exacerbation of orthostatic hypotension 3, 5.