What is the recommended workup and management for a 74-year-old female with confirmed orthostatic hypotension, coronary artery disease (CAD), and vascular disease?

Workup and Management of Orthostatic Hypotension in a 74-Year-Old Female with CAD and Vascular Disease

The recommended workup for confirmed orthostatic hypotension in a 74-year-old female with CAD and vascular disease should include a thorough evaluation for reversible causes, medication review, and targeted testing, followed by a stepwise treatment approach starting with non-pharmacological measures before considering medications. 1

Initial Evaluation

Medication Review

• Identify and discontinue or modify medications that may cause or worsen orthostatic hypotension:
  • Antihypertensives (especially vasodilators)
  • Diuretics
  • Antipsychotics
  • Tricyclic antidepressants
  • Alpha-blockers
  • Cardiac glycosides (when used with midodrine) 2

Laboratory Testing

• Complete blood count (to rule out anemia)
• Basic metabolic panel (electrolytes, renal function)
• Liver function tests (especially if considering pharmacologic therapy) 2
• Blood glucose (to evaluate for diabetes)
• Thyroid function tests

Cardiovascular Assessment

• Coronary angiography is reasonable given patient's age >40 years and existing CAD and vascular disease 3
• Consider 64-detector-row or higher CTA if pretest probability of new CAD is low to intermediate 3
• Evaluate for cardiac causes of orthostatic hypotension (heart failure, arrhythmias)

Management Approach

Non-Pharmacological Interventions (First-Line)

1. Increased salt intake (6-10g daily/1-2 teaspoons) unless contraindicated by heart failure or severe hypertension 1
2. Compression garments (thigh-high compression stockings, abdominal binders) providing 30-40 mmHg of pressure 1
3. Physical counter-pressure maneuvers (leg crossing, squatting, muscle tensing) 1
4. Acute water ingestion (500ml, 30 minutes before anticipated orthostatic stress) 1
5. Dietary modifications:
   • Small, frequent meals (4-6 per day)
   • Reduced carbohydrate content
   • Increased dietary fiber and protein
   • Avoiding alcoholic beverages 1
6. Sleeping with head of bed elevated to prevent supine hypertension 2

Pharmacological Interventions (If Non-Pharmacological Measures Insufficient)

1. First-line medication: Midodrine (5-20mg three times daily, with last dose at least 3-4 hours before bedtime) 1, 2

   • Monitor for supine hypertension
   • Start at lower dose (2.5mg) in patients with renal impairment 2
   • Avoid in patients with urinary retention problems 2

2. Alternative first-line: Fludrocortisone (0.1-0.3mg daily) 1

   • Monitor for fluid retention, hypokalemia, and supine hypertension
   • Use cautiously in patient with CAD and vascular disease

3. Second-line options (if first-line inadequate):

   • Droxidopa (100-600mg three times daily) 1
   • Pyridostigmine (30mg 2-3 times daily) 1

Monitoring

• Regular blood pressure measurements in both supine and standing positions 1
• Monitor for supine hypertension (BP >180/110 mmHg) 1
• Evaluate treatment efficacy based on symptom improvement rather than absolute BP values 1
• Regular weight assessment to evaluate fluid status 1
• Electrolyte monitoring, particularly potassium and sodium 1

Special Considerations for This Patient

• Given patient's age and cardiovascular comorbidities, start medications at lower doses and titrate slowly 1
• Closely monitor for supine hypertension, especially with pharmacologic therapy 1, 2
• If using midodrine, be cautious with concomitant cardiac glycosides due to potential for bradycardia 2
• If beta-blockers are needed for CAD management, start at very low doses due to potential worsening of orthostatic hypotension 1

Common Pitfalls to Avoid

1. Focusing on BP numbers rather than symptoms 1
2. Overlooking non-pharmacological measures 1
3. Improper timing of medications (administering vasopressors too close to bedtime) 1, 2
4. Inadequate monitoring for supine hypertension 1, 2
5. Failure to discontinue contributing medications 1

By following this comprehensive approach, orthostatic hypotension can be effectively managed in this elderly patient with significant cardiovascular comorbidities, improving quality of life while minimizing risks.