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Syncope and Hypotension in the Elderly Patient Lewis A. Lipsitz, MD Hebrew SeniorLife, Beth Israel Deaconess Medical Center, Harvard Medical School Disclosures:

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Presentation on theme: "Syncope and Hypotension in the Elderly Patient Lewis A. Lipsitz, MD Hebrew SeniorLife, Beth Israel Deaconess Medical Center, Harvard Medical School Disclosures:"— Presentation transcript:

1 Syncope and Hypotension in the Elderly Patient Lewis A. Lipsitz, MD Hebrew SeniorLife, Beth Israel Deaconess Medical Center, Harvard Medical School Disclosures: None

2 Syncope Definition Transient loss of consciousness, characterized by unresponsiveness and loss of postural tone, with spontaneous recovery.

3 Epidemiology of Syncope Prevalence up to 47% in healthy young 23% 10-year pevalence in the NH pop. 6-33% 1-year mortality in pts. over 60. $2 Billion annual costs. Up to 40% of cases remain unexplained, despite extensive inpatient evaluations.

4 Syncope Case 1 An 88 year old nursing home resident with hypertension, CAD, and mild dementia was found unresponsive and slumped in her chair, 1 hour after breakfast. She had taken isosorbide dinitrate, metoprolol, lisinopril, and HCTZ before breakfast. Her BP was 105/72, pulse was 64.

5 Syncope Case 2 An active 75 y.o. man with no active medical problems suddenly became dizzy and fainted while cleaning his apartment. A friend found him and rushed him to the hospital where he was admitted and ruled out for an MI. A head CT and exercise stress test were normal. BP and P were: 158/92, 72 supine and 90/62, 72 standing.

6 Syncope Etiology Only if one knows the causes of syncope will he be able to recognize its onset and combat the cause. Miamonides 1135-1204 CE

7 Etiology of Syncope in the NH DiseasesNo. of Patients Myocardial Infarction6 Aortic Stenosis5 Dehydration4 Seizure Disorder3 Cerebrovascular Event3 Cardiac Ischemia3 Tachy-Brady Syndrome3 Lipsitz, LA, J Chronic Ds, 1986; 39:619

8 Etiology of Syncope - 2 DiseasesNo. of Patients Acute respiratory failure2 Cervical Spondylosis1 Sinus arrest1 Paroxysmal atrial tachycardia1 Carotid sinus syndrome1 Heart block1

9 Etiology of Syncope - 3 Situational StressesNo. of Patients Drug-induced hypotension11 Postprandial hypotension 8 Defecation/colostomy irrigation 7 Orthostatic hypotension 6 Fecal impaction 3 Vomiting 1 Micturition 1 Bending over 1

10 Etiology of Syncope - 4 UnknownNo. of Patients No identifiable precipitants17 Unexplained hypotension 8

11 Elderly patients are at risk of hypotension during common daily activities.

12 Age-related Changes in BP Regulation Decreased cerebral blood flow Baroreflex impairment Reduced renal salt and water conservation Impaired early diastolic ventricular filling

13 Aging BP Elevation Impaired BP Regulation Hypotension Cerebral Hypoperfusion Aging, Hypertension, and BP Regulation

14 Blood Pressure Equation BP = HR x SV x SVR

15 Cardiovagal baroreflex gain declines with age. Gribbin et al. Circ. Research, 29:426, 1971

16 Age-related Changes in Plasma Norepinephrine

17 Davy et al, HTN 1998 Aged-related Increase in Sympathetic Response to Orthostatic Stress

18 Davy et al, HTN 1998 Age-related Decrease in Vascular Response to Sympathetic Activity

19 Reduced Salt and Water Conservation Adapted from Epstein, et al, Fed Proc 1979; 170.

20 Age-related Change in Plasma Renin Activity

21 Diastolic Dysfunction A A Normal transmitral Doppler ventricular inflow pattern Reduced early, increased late diastolic ventric.filling

22 190 170 150 130 110 90 SUPSTDBREAKSTD/AMBNTGSTDAMBMEDLUNCHSTD 78 9 1011121 Time (hours) SBP (mm Hg) old young



25 The Higher You Are, The Farther You Fall

26 Honolulu Heart Study Prevalence of OH* Age Masaki, Circulation 1998;98:2290 * 3 min stdg

27 Prevalence of OH by Age

28 Prevalence of OH by Level of Supine SBP

29 Prevalence of OH by Age if Supine SBP > 160 mmHg

30 Effect of Hypotension on the Brain

31 Role of Medications in Hypotension and Syncope?

32 The effect of HCTZ and mild volume contraction on BP response to tilt in healthy young and elderly subjects. Shannon RP, et al, Hypertension 8:438, 1986

33 Orthostatic Hypotension is Reduced By Chronic Antihypertensive Therapy Masuo et al. AJH 1996; 9: 263-8



36 Does Antihypertensive Therapy Threaten Cerebral Blood Flow? Sit-to-stand Procedure Avoids hydrostatic changes in perfusion pressure (vs. tilt). Simulates a common activity of daily living. Causes rapid and reproducable declines in arterial pressure.

37 Effect of 6 Months of BP Control on Cerebral Blood Flow Lipsitz, et. al., Hypertension, 2005


39 What’s Different About Syncope in Elderly People? Multiple Pathologic Conditions Situational Hypotension –Postprandial –Drug-induced –Orthostatic Cardiovascular causes > vasovagal Vasovagal prodrome is less common. Reflex Syncope - e.g. Carotid Sinus Synd.

40 Syncope Evaluation Hx of diseases, drugs, and precipitants PE for CV ds., neuro signs, GI bleeding BP during activities preceding syncope: posture change, meals & medications. Carotid sinus massage (if no CVD or cardiac conduction disease) Focused laboratory studies

41 Syncope Evaluation - Labs For most patients: EKG, Chem screen, CBC. If cardiac sx, or abnormal EKG - r/o MI If Hx of CVD - ambulatory cardiac monitor If situational - ambulatory BP monitoring If suspicious murmur - cardiac echo/Doppler If focal neuro findings or Seizures - EEG/CT If unexplained - Tilt and EPS

42 Whom to Admit? Boston Syncope Rule (97% Sens., 62% Spec. for adverse outcome or critical intervention (Grossman, JEM 2007)) 1) Signs and sx of an acute coronary syndrome; 2) Signs of conduction disease; 3) Worrisome cardiac history; 4) Valvular heart disease by history or physical; 5) Family history of sudden death; 6) Persistent abnormal vital signs in the ED; 7) Volume depletion such as persistent dehydration, GI bleeding, or hematocrit < 30; and 8) Primary CNS event.

43 Definition of Orthostatic Hypotension 20 mmHg or greater decline in systolic BP and/or 10 mmHg or greater decline in diastolic BP when changing from a supine to upright position (sitting or standing). 1 and/or 3 minute value. HR is not a reliable indicator in geriatric patients because of baroreflex impairment.

44 Causes of OH Systemic –Hypertension –Dehydration –Deconditioning –Adrenocortical insufficiency Drugs –Antipsychotics –MAOs & tricyclics –antihypertensives (acute doses) –vasodilators (NTG) –L-Dopa –BBs, CCB’s, etc.

45 Causes of OH CNS Disorders –Multiple Systems Atrophy –Parkinson’s Disease –Multiple Strokes –Myelopathy –Brain stem lesions Autonomic Neuropathy –Diabetes Mellitus –Amyloidosis –Tabes Dorsalis –Paraneoplastic –Alcohol –Nutritional

46 Evaluation of OH Sx: Postural dizziness, falls, or syncope; po intake; abnl. sweating, incontinence, HA,GI dysmotility, impotence, poor night vision. Hx: HTN, DM, CA, Stroke, Parkinsons, Arrhythmias, Meds & alcohol. PE: BP & P supine, 1 & 3 min stdg; pupils, skin, CV and neuro exams. Labs: Hct, Lytes, Glu, SPEP, B12, RPR +/- cortisol, brain imaging, tilt with NE levels, HRV during deep breathing & Valsalva, sweat tests.

47 Nonpharmacologic RX of OH Drug withdrawal, substitution or reduction Avoid warm environment Avoid straining activity Squatting, leg crossing Increase salt intake Waist-high compression stockings Sleeping in the head-up position

48 Definition of PPH 20 mm Hg or greater decline in systolic BP within 2 hours of the start of a meal.

49 PPH - Clinical Associations Patients with HTN, autonomic insufficiency, Parkinson’s Disease, Diabetes, Renal failure 24-36% of nursing home residents. 23% of elderly patients admitted to a geriatric hospital with syncope or falls. 50% of elderly pts. with unexplained syncope Angina, TIA’s, lacunar infarcts, leukoaraiosis

50 Evaluation of PPH BP pre & post meal: 400 kcal, 70- 80% CHO. Hx: Meds, EtOH, autonomic Sx, HTN, DM, CVD, Parkinson’s, autonomic neuropathy. post-meal EKG to r/o angina. consider dumping syndrome.

51 Nonpharmacologic Rx of PPH Stop hypotensive meds or give between meals. Avoid preload reduction (diuretics or prolonged sitting), maintain adequate intravascular vol. Avoid EtOH. Multiple small meals of protein and fat. Walking exercise after meals (frail elderly). ? cold rather than warm meals.

52 Walk

53 Nach dem essen sollst du ruhen oder tausand schritte tuen. -German folk wisdom

54 Pharmacologic Rx of OH and PPH Caffeine: 250 mg (2 cups brewed) in AM Fludrocortisone: 0.1 to 1.0 mg QD (watch for CHF, supine HTN, and hypokalemia. Midodrine: 2.5-10 mg po TID (supine HTN) Octreotide: 50  g subQ, 30 min. pre-meals

55 Challenges and Unmet Needs 1. Causes of Unexplained Syncope? –Neurally-mediated (vasovagal): fewer premonitory sx in elderly patients. –Dysautonomia –Paroxysmal brady- or tachy-arrhythmias –Carotid Sinus Hypersensitivity 2. Better Diagnostic tools – Tilt tests, EPS, BP monitoring? Validate Syncope Rule in Elderly 3. Methods to improve cerebral perfusion.

56 Principles of Treatment Treat the primary etiology if one is found. Age is NOT a contraindication to treatment, but increases the risk of drugs and surgery. Identify and minimize the impact of multiple contributors, particularly drugs. Behavioral interventions to avoid situational hypotension.

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