What are the next steps for a patient with hypotension (Blood Pressure 104/58 mmHg), diplopia (double vision), and dizziness?

From the Guidelines

If you're experiencing a blood pressure of 104/58 along with double vision and dizziness, you should seek immediate medical attention, ideally by calling emergency services (911) or having someone take you to the emergency room. These symptoms together could indicate a serious neurological issue such as a stroke, vertebrobasilar insufficiency, or other conditions requiring urgent evaluation, as suggested by the 2024 guidelines for the management of elevated blood pressure and hypertension 1. While your blood pressure is on the lower side of normal, the combination with neurological symptoms is concerning. At the hospital, healthcare providers will likely perform a thorough neurological examination, blood tests, and possibly imaging studies such as a CT scan or MRI of your brain, as the symptoms may be related to abducens palsy, which can be caused by various factors including vasculopathy, trauma, or neoplasm, as discussed in the adult strabismus preferred practice pattern 1. They may also check your blood sugar levels, as hypoglycemia can cause similar symptoms. Don't attempt to drive yourself to the hospital, as your double vision and dizziness make this dangerous. While waiting for medical help, lie down in a safe position, preferably on your side, and avoid eating or drinking in case emergency procedures are needed. These symptoms require professional evaluation as they could indicate a life-threatening condition that needs immediate treatment, and the European Heart Journal suggests that patients with orthostatic hypotension should be assessed and managed accordingly 1. Additionally, the management of orthostatic hypotension may involve non-pharmacological approaches, such as ensuring adequate salt intake and avoiding medications that aggravate hypotension, as well as pharmacologic measures, including midodrine and droxidopa, which are approved by the FDA for the treatment of orthostatic hypotension 1.

Some key points to consider in the management of these symptoms include:

• The importance of immediate medical attention
• The need for a thorough neurological examination and possible imaging studies
• The potential causes of the symptoms, including abducens palsy and orthostatic hypotension
• The management of orthostatic hypotension, including non-pharmacological and pharmacologic approaches
• The importance of avoiding driving and other activities that may be dangerous due to the symptoms.

It is essential to prioritize the patient's safety and well-being, and to seek medical attention immediately if the symptoms persist or worsen, as suggested by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

From the FDA Drug Label

The patient should be cautioned to report symptoms of supine hypertension immediately. Symptoms may include cardiac awareness, pounding in the ears, headache, blurred vision, etc. Midodrine should be used with caution in orthostatic hypotensive patients who are also diabetic, as well as those with a history of visual problems who are also taking fludrocortisone acetate, which is known to cause an increase in intraocular pressure and glaucoma.

The patient's symptoms of hypotension (Blood Pressure 104/58 mmHg), diplopia (double vision), and dizziness may be related to orthostatic hypotension.

• The next steps would be to monitor blood pressure and assess for supine hypertension.
• Caution should be exercised when using midodrine, especially in patients with a history of visual problems or diabetes.
• Patients should be advised to report symptoms of supine hypertension immediately and to avoid taking their dose if they are to be supine for any length of time 2 2.

From the Research

Next Steps for Patient with Hypotension, Diplopia, and Dizziness

The patient's symptoms of hypotension (blood pressure 104/58 mmHg), diplopia (double vision), and dizziness may be indicative of orthostatic hypotension, a condition characterized by a decrease in blood pressure upon standing associated with symptoms of lightheadedness, dizziness, and visual disturbances 3, 4.

• Nonpharmacologic Therapies: The first step in managing the patient's condition is to educate them about the pathophysiology and course of their disorder. Nonpharmacologic therapies and maneuvers, such as increasing fluid and salt intake, venous compression methods, and physical countermaneuvers, may be effective in relieving symptoms and preventing syncope 5, 6.
• Pharmacologic Options: If the patient's symptoms are severe, pharmacologic options such as fludrocortisone and midodrine may be considered. Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension 7. Midodrine, an alpha-1-agonist, has been shown to produce arteriolar constriction and decrease in venous pooling, and is an effective and safe agent for the treatment of neurogenic orthostatic hypotension 3, 4.
• Supine Hypertension: The patient's supine hypertension may represent a challenge in the treatment of their condition, and elevation of the bed of the head and dosing of short-acting antihypertensive agents at bedtime may be indicated 5.
• Monitoring and Follow-up: The patient's condition should be closely monitored, and their treatment plan should be adjusted as needed to minimize symptoms and improve standing time, without excessive supine hypertension 6.