Hipotensión arterial ortostática - Disautonomías y síncope

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Hipotensión arterial ortostática

Disautonomías
Diferentes tipos de hipotensión arterial ortostática
La primera imagen nos recuerda los diferentes tipos de HO, la inicial, la precoz o clásica y la tardía. El diagrama siguiente nos muestra la HO inicial, la del primer minuto. Luego la precoz o clásica y la HO tardía. En este caso hay HO después del tercer minuto, con velocidad de instalación variable y concomitantemente aumento de la frecuencia cardiaca.
Clasificación de la hipotensión arterial ortostática: en la actualidad se consideran 3 tipos de hipotensión arterial ortostática: inicial, precoz o clásica y tardía. La definición clásica de hipotensión ortostática (HO) y por consenso es un descenso de a lo menos 20 mmHg en la presión sistólica o de 10 mmHg en la presión diastólica, al ponerse de pie en forma activa o bien en la mesa de tilt test, y en los primeros tres minutos de la maniobra [1-24]. Este concepto clásico ha sido sobrepasado por los hechos de que son entidades distintas, en grupos etarios algo diferentes y de diferente pronóstico [25].
 
Hipotensión ortostática inicial: Corresponde a la hipotensión arterial que ocurre al primer minuto de ponerse de pie. El criterio es un descenso de la presión arterial de 40/20 mmHg o más en el primer minuto, ya sea en la presión sistólica o máxima o en la diastólica o mínima. Los síntomas son a los 5-10 segundos, en especial después de estar acostado o en cuclillas [26-29].
 
Hipotensión ortostática precoz o clásica: ya definida al inicio. Sólo agregar criterios adicionales en los últimos consensos. Estos criterios han sido actualizados y en los pacientes hipertensos se requiere una caía de 30 mmHg de la presión sistólica y un criterio adicional es un descenso absoluto de la presión sistólica menos de 90 mmHg [12, 15].
 
Hipotensión ortostática tardía: igual que la hipotensión arterial ortostática precoz, pero después del tercer minuto hasta el minuto 45 de estar de pie o en la mesa basculante [30-34].
Bibliografía.

1.Schatz I, Bannister R, Freeman R, Goetz C, Jankovic J, Kaufmann H, Koller W, Low P, Mathias C, Polinsky R: The definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. In: Elsevier Science BV PO BOX 211, 1000 AE Amsterdam, Netherlands,  (1996).

2.Aronow WS: Orthostatic hypotension. In: Hypotensive syndromes in geriatric patients. Springer,  (2020):1-8.

3.Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martin A, Probst V et al: 2018 esc guidelines for the diagnosis and management of syncope. Eur Heart J (2018) 39(21):1883-1948.

4.Cheshire WP: Clinical classification of orthostatic hypotensions. Clinical Autonomic Research (2017) 27(3):133-135.

5.Cowan H: Orthostatic hypotension: The last 20 years. British Journal of Cardiac Nursing (2020) 15(4):1-4.

6.Fanciulli A, Jordan J, Biaggioni I, Calandra–Buonaura G, Cheshire WP, Cortelli P, Eschlboeck S, Grassi G, Hilz MJ, Kaufmann H: Consensus statement on the definition of neurogenic supine hypertension in cardiovascular autonomic failure by the american autonomic society (aas) and the european federation of autonomic societies (efas). Clinical Autonomic Research (2018) 28(4):355-362.

7.Mar PL, Raj SR: Orthostatic hypotension for the cardiologist. Curr Opin Cardiol (2018) 33(1):66-72.

8.Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B et al: 2017 acc/aha/hrs guideline for the evaluation and management of patients with syncope: Executive summary: A report of the american college of cardiology/american heart association task force on clinical practice guidelines and the heart rhythm society. Heart Rhythm (2017) 14(8):e218-e254.

9.Tzur I, Izhakian S, Gorelik O: Orthostatic hypotension: Definition, classification and evaluation. Blood pressure (2019) 28(3):146-156.

10.Wieling W, Schatz IJ: The consensus statement on the definition of orthostatic hypotension: A revisit after 13 years. In: J hypertens. 27.  (2009):935-938.

11.McJunkin B, Rose B, Amin O, Shah N, Sharma S, Modi S, Kemper S, Yousaf M: Detecting initial orthostatic hypotension: A novel approach. Journal of the American Society of Hypertension (2015) 9(5):365-369.

12.Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT et al: Pediatric disorders of orthostatic intolerance. Pediatrics (2018) 141(1).

13.van Wijnen VK, Harms MP, Go-Schön IK, Westerhof BE, Krediet C, Stewart J, Wieling W: Initial orthostatic hypotension in teenagers and young adults. Clinical Autonomic Research (2016) 26(6):441-449.

14.van Wijnen VK, Ten Hove D, Finucane C, Wieling W, van Roon AM, Ter Maaten JC, Harms MP: Hemodynamic mechanisms underlying initial orthostatic hypotension, delayed recovery and orthostatic hypotension. Journal of the American Medical Directors Association (2018) 19(9):786-792
.
15.Wieling W, Krediet CP, Van Dijk N, Linzer M, Tschakovsky ME: Initial orthostatic hypotension: Review of a forgotten condition. Clinical science (2007) 112(3):157-165.

16.Stewart JM, Clarke D: “He’s dizzy when he stands up”: An introduction to initial orthostatic hypotension. The Journal of pediatrics (2011) 158(3):499-504.

17.Low P: Prevalence of orthostatic hypotension. Clin Auton Res (2008) 18 (Suppl 1)(8-13.

18.Saedon NIz, Pin Tan M, Frith J: The prevalence of orthostatic hypotension: A systematic review and meta-analysis. The Journals of Gerontology: Series A (2020) 75(1):117-122.

19.Gibbons CH, Freeman R: Delayed orthostatic hypotension: A frequent cause of orthostatic intolerance. Neurology (2006) 67(1):28-32.

20.Kearney F, Moore A: Treatment of combined hypertension and orthostatic hypotension in older adults: More questions than answers still remain. Expert Review of Cardiovascular Therapy (2009) 7(6):557-560.

21.Naschitz J, Slobodin G, Elias N, Rosner I: The patient with supine hypertension and orthostatic hypotension: A clinical dilemma. Postgraduate medical journal (2006) 82(966):246-253.

22.Dumas E, Jalil, J : Pruebas autonómicas en la evaluación de la actividad cardiovascular refleja en población sana: Valores normales. . Revista Chilena de Cardiologia (2004) 23(280.

23.Brignole M, Moya A, de Lange FJ, Deharo J-C, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A: 2018 esc guidelines for the diagnosis and management of syncope. European heart journal (2018) 39(21):1883-1948.

24.Freeman R, Abuzinadah AR, Gibbons C, Jones P, Miglis MG, Sinn DI: Orthostatic hypotension: Jacc state-of-the-art review. Journal of the American College of Cardiology (2018) 72(11):1294-1309.

25.Alagiakrishnan K: Non-pharmacological management of hypotensive syndromes. In: Hypotensive syndromes in geriatric patients. Springer,  (2020):65-74.

26.Subbarayan S, Myint PK, Martin KR, Abraha I, Devkota S, O'Mahony D, Cruz-Jentoft AJ, Cherubini A, Soiza RL: Nonpharmacologic management of orthostatic hypotension in older people: A systematic review. The senator ontop series. Journal of the American Medical Directors Association (2019) 20(9):1065-1073. e1063.

27.McCullough PA: Treatment of orthostatic hypotension due to autonomic dysfunction (neurogenic orthostatic hypotension) in a patient with cardiovascular disease and parkinson's disease. Cardiology and therapy (2019) 8(1):145-150.

28.Lewis A, Galetta S: Editors' note: The efficacy of nonpharmacologic intervention for orthostatic hypotension associated with aging. Neurology (2019) 92(14):682-682.

29.Cheshire WP: Chemical pharmacotherapy for the treatment of orthostatic hypotension. Expert opinion on pharmacotherapy (2019) 20(2):187-199.

30.Palma JA, Kaufmann H: Epidemiology, diagnosis, and management of neurogenic orthostatic hypotension. Mov Disord Clin Pract (2017) 4(3):298-308.

31.Kaufmann H, Palma JA: Neurogenic orthostatic hypotension: The very basics. In: Clin auton res. 27. Germany (2017):39-43.

32.Arnold AC, Raj SR: Orthostatic hypotension: A practical approach to investigation and management. Can J Cardiol (2017) 33(12):1725-1728.

33.Freeman R: Current pharmacologic treatment for orthostatic hypotension. Clinical Autonomic Research (2008) 18(1):14-18.

34.Fouad FM, Maloney, J.: Orthostatic hypotension: Diagnosis and management. Cardiology and therapy (1990) 60-66.

35.Tzur I, Izhakian S, Gorelik O: Orthostatic hypotension in internal medicine wards. Current medical research and opinion (2019) 35(6):947-955.

36.Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, Stoyanovsky V, Antikainen RL, Nikitin Y, Anderson C: Treatment of hypertension in patients 80 years of age or older. New England Journal of Medicine (2008) 358(18):1887-1898.

37.Kanis JA, Johnell O, Oden A: Frax®  and the assessment of fracture probability in men and women from the uk. Osteoporosis (2008) 19(385-397.

38.Turnbull F, Arima H, Heeley E: Cardiovascular risk management among female and male patients in australian general practice: The ausheart study. Heart, Lung and Circulation (2009) (suppl 3) 18(S272.

39.Beckett NS, Peters R, Fletcher AE: Treatment of hypertension in patients 80 years of age or older. N Engl J Med (2008) 358(18):1887-1898.

40.Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M: Guía esc/esh 2018 sobre el diagnóstico y tratamiento de la hipertensión arterial. Rev Esp Cardiol (2019) 72(2):160.

41.Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Himmelfarb CD, DePalma SM, Gidding S, Jamerson KA, Jones DW: 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the american college of cardiology/american heart association task force on clinical practice guidelines. Journal of the American College of Cardiology (2018) 71(19):e127-e248.

42.Kearney F, Moore A: Treatment of combined hypertension and orthostatic hypotension in older adults: More questions than answers still remain. Expert Rev Cardiovasc Ther (2009) 7(557-560.

43.Stokes GS: Management of hypertension in the elderly patient. Clinical interventions in Aging (2009) 4(379-389.

44.Messerli FH, Grossman E, Goldbourt U: Are β-blockers efficacious as first-line therapy for hypertension in the elderly?: A systematic review. Jama (1998) 279(23):1903-1907.

45.Pasco JA, Henry MJ, Sanders KM, Kotowicz MA, Seeman E, Nicholson GC: Β‐adrenergic blockers reduce the risk of fracture partly by increasing bone mineral density: Geelong osteoporosis study. Journal of bone and mineral research (2004) 19(1):19-24.

46.Jordan J, Tank J, Heusser K, Reuter H, Biaggioni I: What do we really know about supine hypertension in patients with orthostatic hypotension. Current opinion in cardiology (2019) 34(4):384-389.

47.Jordan J, Fanciulli A, Tank J, Calandra-Buonaura G, Cheshire WP, Cortelli P, Eschlboeck S, Grassi G, Hilz MJ, Kaufmann H: Management of supine hypertension in patients with neurogenic orthostatic hypotension: Scientific statement of the american autonomic society, european federation of autonomic societies, and the european society of hypertension. Journal of hypertension (2019) 37(8):1541-1546.

48.Arnold AC, Okamoto LE, Gamboa A, Black BK, Raj SR, Elijovich F, Robertson D, Shibao CA, Biaggioni I: Mineralocorticoid receptor activation contributes to the supine hypertension of autonomic failure. Hypertension (2016) 67(2):424-429.

49.Shannon JR, Jordan J, Diedrich A, Pohar B, Black BK, Robertson D, Biaggioni I: Sympathetically mediated hypertension in autonomic failure. Circulation (2000) 101(23):2710-2715.

50.Arnold AC, Biaggioni I: Management approaches to hypertension in autonomic failure. Current opinion in nephrology and hypertension (2012) 21(5):481.

51.Gamboa A, Shibao C, Diedrich A, Paranjape SY, Farley G, Christman B, Raj SR, Robertson D, Biaggioni I: Excessive nitric oxide function and blood pressure regulation in patients with autonomic failure. Hypertension (2008) 51(6):1531-1536.

52.Shannon J, Jordan J, Costa F, Robertson RM, Biaggioni I: The hypertension of autonomic failure and its treatment. Hypertension (1997) 30(5):1062-1067.

53.Okamoto LE, Gamboa A, Shibao CA, Arnold AC, Choi L, Black BK, Raj SR, Robertson D, Biaggioni I: Nebivolol, but not metoprolol, lowers blood pressure in nitric oxide–sensitive human hypertension. Hypertension (2014) 64(6):1241-1247.

54.Cheshire WP, Phillips LH: Delayed orthostatic hypotension: Is it worth the wait? In: AAN Enterprises,  (2006).

55.Gibbons CH, Freeman R: Clinical implications of delayed orthostatic hypotension: A 10-year follow-up study. Neurology (2015) 85(16):1362-1367.

56.Madhavan M, DeSimone CV, Mulpuru S, Asirvatham SJ: Renal nerve stimulation for the treatment of neurocardiogenic syncope. Cardiovascular Revascularization Medicine (2013) 14(3):172-173.

57.Streeten DP, Anderson GH, Jr: Delayed orthostatic intolerance. Archives of Internal Medicine (1992) 152(5):1066-1072.

58.De Lorenzo F, Hargreaves J, Kakkar V: Pathogenesis and management of delayed orthostatic hypotention in patients with chronic fatigue syndrome. Clinical Autonomic Research (1997) 7(4):185-190.

59.Fedorowski A, van Wijnen VK, Wieling W: Delayed orthostatic hypotension and vasovagal syncope: A diagnostic dilemma. In: Clin auton res. 27. Germany (2017):289-291.

60.Tzur I, Barchel D, Khateb Z, Swarka M, Izhakian S, Gorelik O: Delayed versus classic orthostatic hypotension: Clinical and prognostic implications. Blood pressure (2020) 1-11.

61.Torabi P, Ricci F, Hamrefors V, Sutton R, Fedorowski A: Classical and delayed orthostatic hypotension in patients with unexplained syncope and severe orthostatic intolerance. Frontiers in Cardiovascular Medicine (2020) 7(21.

62.Dumas E, G.; Cohen, S.; Jalil, J.: Análisis espectral en el diagnóstico de la intolerancia ortostática hiperadrenérgica. Rev Chilena de Cardiología (2003) 22(157.

63.Streeten DH: Pathogenesis of hyperadrenergic orthostatic hypotension. Evidence of disordered venous innervation exclusively in the lower limbs. Journal of Clinical Investigation (1990) 86(5):1582-1588.

64.Streeten DH: Variations in the clinical manifestations of orthostatic hypotension. 70:Abs 713-714.

65.Streeten DH, Anderson GH, Jr.: The role of delayed orthostatic hypotension in the pathogenesis of chronic fatigue. Clin Auton Res (1998) 8(2):119-124.

66.Streeten DH, Anderson GH, Jr., Richardson R, Thomas FD: Abnormal orthostatic changes in blood pressure and heart rate in subjects with intact sympathetic nervous function: Evidence for excessive venous pooling. J Lab Clin Med (1988) 111(3):326-335.

67.Streeten DH, Scullard TF: Excessive gravitational blood pooling caused by impaired venous tone is the predominant non-cardiac mechanism of orthostatic intolerance. Clin Sci (Lond) (1996) 90(4):277-285.

68.Thomopoulos C, Parati G, Zanchetti A: Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 13–benefits and adverse events in older and younger patients with hypertension: Overview, meta-analyses and meta-regression analyses of randomized trials. Journal of hypertension (2018) 36(8):1622-1636.

69.Lim GB: Low sodium and dash diet to lower blood pressure. Nature Reviews Cardiology (2018) 15(2):68-68.

70.Sundström J, Arima H, Jackson R, Turnbull F, Rahimi K, Chalmers J, Woodward M, Neal B: Effects of blood pressure reduction in mild hypertension: A systematic review and meta-analysis. Annals of internal medicine (2015) 162(3):184-191.

71.Zanchetti A, Grassi G, Mancia G: When should antihypertensive drug treatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal. Journal of hypertension (2009) 27(5):923-934.

72.Mancia G, Laurent S, Agabiti-Rosei E, Ambrosioni E, Burnier M, Caulfield MJ, Cifkova R, Clément D, Coca A, Dominiczak A: Reappraisal of european guidelines on hypertension management: A european society of hypertension task force document. Blood pressure (2009) 18(6):308-347.

73.López-Jaramillo P, López-López J: Determinantes sociales de salud y enfermedad cardiometabólica. Aportes de la investigación latinoamericana. Acta Médica Colombiana (2016) 41(3):29-37.

74.Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, Fine LJ, Haley WE, Hawfield AT, Ix JH: Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged≥ 75 years: A randomized clinical trial. Jama (2016) 315(24):2673-2682.

75.Dagenais GR, Jung H, Lonn E, Bogaty PM, Dehghan M, Held C, Avezum A, Jansky P, Keltai M, Leiter LA: Effects of lipid‐lowering and antihypertensive treatments in addition to healthy lifestyles in primary prevention: An analysis of the hope‐3 trial. Journal of the American Heart Association (2018) 7(15):e008918.

76.Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A: The task force for the management ofarterial hypertension of the european society ofhypertension (esh) and of the european society of cardiology (esc). Journal of Hypertension (2013) 31(7):1281-1357.

77.Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney M-T, Corra U, Cosyns B, Deaton C: 2016 european guidelines on cardiovascular disease prevention in clinical practice: The sixth joint task force of the european society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the european association for cardiovascular prevention & rehabilitation (eacpr). European heart journal (2016) 37(29):2315-2381.
        
Dr. Eduardo Dumas Rossi
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