What are the implications of isolated diastolic hypotension?

From the Guidelines

Isolated diastolic hypotension should not be treated with the goal of raising diastolic blood pressure, but rather by addressing underlying causes and monitoring for potential complications, as evidenced by the lack of clear benefit from treating low diastolic blood pressure in the Syst-Eur trial 1. In patients with isolated diastolic hypotension, it is essential to identify and manage underlying causes, such as dehydration, endocrine disorders, or autonomic dysfunction, rather than focusing solely on raising diastolic blood pressure. Some key considerations in managing isolated diastolic hypotension include:

• Maintaining adequate hydration to prevent dehydration-related hypotension
• Avoiding sudden position changes to prevent dizziness and falls
• Considering sodium intake adjustments if appropriate, as guided by individual patient needs and medical history
• Regular blood pressure monitoring to track patterns and identify potential complications
• Medical evaluation if symptoms like dizziness, fatigue, or cognitive changes are present, or if readings consistently fall below 60 mmHg, to identify and address underlying causes. The optimum diastolic blood pressure to be achieved by treatment is not clear, and some studies suggest that lowering diastolic blood pressure too much may be associated with increased risk, particularly in patients with a history of coronary heart disease 1. Therefore, a cautious approach is warranted, prioritizing the management of underlying causes and monitoring for potential complications, rather than aggressively treating isolated diastolic hypotension.

From the Research

Isolated Diastolic Hypotension

• Isolated diastolic hypotension refers to a condition where the diastolic blood pressure is lower than normal, while the systolic blood pressure is within the normal range.
• There is limited research available on isolated diastolic hypotension, as most studies focus on orthostatic hypotension or hypertension.
• However, a study on the clinical significance of isolated diastolic hypertension 2 suggests that isolated diastolic hypotension may not be a significant concern in older adults, as it is not associated with adverse cardiovascular events in this population.

Treatment of Orthostatic Hypotension

• Orthostatic hypotension is a condition characterized by a significant drop in blood pressure when standing up from a sitting or lying down position.
• Treatment options for orthostatic hypotension include non-pharmacological strategies such as increasing fluid and salt intake, wearing compression stockings, and avoiding large meals 3.
• Pharmacological treatments include midodrine, droxidopa, fludrocortisone, and pyridostigmine, which can help increase blood pressure and alleviate symptoms 4, 5, 3.

Fludrocortisone Therapy

• Fludrocortisone is a mineralocorticoid that can help increase blood volume and blood pressure.
• Studies have shown that fludrocortisone can be effective in treating orthostatic hypotension, particularly in patients with diabetes or Parkinson's disease 5.
• However, fludrocortisone therapy can also have adverse effects, such as supine hypertension, hypokalemia, and edema 5, 6.

Midodrine Therapy

• Midodrine is a prodrug that is converted to desglymidodrine, a selective alpha 1-adrenoceptor agonist, after oral administration.
• Midodrine has been shown to be effective in increasing standing systolic blood pressure and improving symptoms of orthostatic hypotension 4.
• Midodrine is generally well-tolerated, with common adverse effects including piloerection, pruritus, and urinary retention 4.