Hypotension

In physiology and medicine, hypotension is low blood

pressure, especially in the arteries of the systemic circulation.[1] Blood pressure is the force of blood pushing
against the walls of the arteries as the heart pumps out
blood. Hypotension is generally considered systolic blood
pressure less than 90 millimeters of mercury (mm Hg) or
diastolic less than 60 mm Hg.[2][3] However, in practice,
blood pressure is considered too low only if noticeable
symptoms are present.[4]

dyspepsia (indigestion)

Hypotension is the opposite of hypertension, which

is high blood pressure. It is best understood as a
physiological state, rather than a disease. It is often associated with shock, though not necessarily indicative of
it.

profound fatigue

dysuria (painful urination)

adverse eect of medications
acute, life-threatening allergic reaction
seizures
loss of consciousness

temporary blurring or loss of vision

connective tissue disorder Ehlers-Danlos Syndrome

Black tarry stools

For some people who exercise and are in top physical condition, low blood pressure is a sign of good health and
tness.[5] For many people, excessively low blood pressure can cause dizziness and fainting or indicate serious 2 Causes
heart, endocrine or neurological disorders. Severely low
blood pressure can deprive the brain and other vital or- Low blood pressure can be caused by low blood volume,
gans of oxygen and nutrients, leading to a life-threatening hormonal changes, widening of blood vessels, medicine
condition called shock.
side eects, anemia, heart problems or endocrine problems.
Reduced blood volume, hypovolemia, is the most common cause of hypotension. This can result from
hemorrhage; insucient uid intake, as in starvation; or
The cardinal symptoms of hypotension include excessive uid losses from diarrhea or vomiting. Hypovolemia is often induced by excessive use of diuretics.
lightheadedness or dizziness.[6]
Low blood pressure may also be attributed to heat stroke.
If the blood pressure is suciently low, fainting and often
The body may have enough uid but does not retain elecseizures occur.
trolytes. Absence of perspiration, light headedness and
Low blood pressure is sometimes associated with certain dark coloured urine are also indicators.
symptoms, many of which are related to causes rather
Other medications can produce hypotension by dierthan eects of hypotension:
ent mechanisms. Chronic use of alpha blockers or beta
blockers can lead to hypotension. Beta blockers can cause
chest pain
hypotension both by slowing the heart rate and by decreasing the pumping ability of the heart muscle.
shortness of breath

Signs and symptoms

Decreased cardiac output despite normal blood volume,

due to severe congestive heart failure, large myocardial
infarction, heart valve problems, or extremely low heart
rate (bradycardia), often produces hypotension and can
rapidly progress to cardiogenic shock. Arrhythmias often
result in hypotension by this mechanism.

irregular heartbeat
fever higher than 38.3 C (101 F)
headache
sti neck

Some heart conditions can lead to low blood pressure,

including extremely low heart rate (bradycardia), heart
valve problems, heart attack and heart failure. These conditions may cause low blood pressure because they prevent the body from being able to circulate enough blood.

severe upper back pain

cough with phlegm
prolonged diarrhea or vomiting
1

Excessive vasodilation, or insucient constriction of the

resistance blood vessels (mostly arterioles), causes hypotension. This can be due to decreased sympathetic nervous system output or to increased parasympathetic activity occurring as a consequence of injury to the brain or
spinal cord or of dysautonomia, an intrinsic abnormality
in autonomic system functioning. Excessive vasodilation
can also result from sepsis, acidosis, or medications, such
as nitrate preparations, calcium channel blockers, or AT1
receptor antagonists (Angiotensin II acts on AT1 receptors). Many anesthetic agents and techniques, including
spinal anesthesia and most inhalational agents, produce
signicant vasodilation.

TREATMENT

Neurocardiogenic syncope is a form of dysautonomia

characterized by an inappropriate drop in blood pressure
while in the upright position. Neurocardiogenic syncope
is related to vasovagal syncope in that both occur as a result of increased activity of the vagus nerve, the mainstay
of the parasympathetic nervous system.

Another, but rarer form, is postprandial hypotension, a

drastic decline in blood pressure that occurs 30 to 75
minutes after eating substantial meals.[13] When a great
deal of blood is diverted to the intestines (a kind of
"splanchnic blood pooling) to facilitate digestion and
absorption, the body must increase cardiac output and peripheral vasoconstriction to maintain enough blood presMeditation, yoga, or other mental-physiological disci- sure to perfuse vital organs, such as the brain. Postprandial hypotension is believed caused by the autonomic nerplines may reduce hypotensive eects.[7]
Lower blood pressure is a side eect of certain vous system not compensating appropriately, because of
botanicals,[8] which can also interact with hypoten- aging or a specic disorder.
sive medications. An example is the theobromine Hypotension is a feature of Flammer syndrome which is
in Theobroma cacao, which lowers blood pressure[9] characterized by cold hands and feet and predisposes to
through its actions as both a vasodilator and a diuretic,[10] normal tension glaucoma.[14]
and has been used to treat high blood pressure.[11][12]

5 Diagnosis
3

Pathophysiology

For most adults, the healthiest blood pressure is at or

below
120/80 mmHg. A small drop in blood presBlood pressure is continuously regulated by the
sure,
even
as little as 20 mmHg, can result in transient
autonomic nervous system, using an elaborate network
[15]
hypotension.
of receptors, nerves, and hormones to balance the eects
of the sympathetic nervous system, which tends to raise Evaluation of neurocardiogenic syncope is done with a tilt
blood pressure, and the parasympathetic nervous system, table test.
which lowers it. The vast and rapid compensation
abilities of the autonomic nervous system allow normal
individuals to maintain an acceptable blood pressure over
6 Treatment
a wide range of activities and in many disease states.

Syndromes

Orthostatic hypotension, also called postural hypotension,

is a common form of low blood pressure. It occurs after a change in body position, typically when a person
stands up from either a seated or lying position. It is usually transient and represents a delay in the normal compensatory ability of the autonomic nervous system. It is
commonly seen in hypovolemia and as a result of various medications. In addition to blood pressure-lowering
medications, many psychiatric medications, in particular
antidepressants, can have this side eect. Simple blood
pressure and heart rate measurements while lying, seated,
and standing (with a two-minute delay in between each
position change) can conrm the presence of orthostatic
hypotension. Orthostatic hypotension is indicated if there
is a drop in 20 mmHg of systolic pressure (and a 10
mmHg drop in diastolic pressure in some facilities) and a
20 beats per minute increase in heart rate.

The treatment for hypotension depends on its cause.

Chronic hypotension rarely exists as more than a symptom. Asymptomatic hypotension in healthy people usually does not require treatment. Adding electrolytes to a
diet can relieve symptoms of mild hypotension. A morning dose of caeine can also be eective. In mild cases,
where the patient is still responsive, laying the person in
dorsal decubitus (lying on the back) position and lifting
the legs increases venous return, thus making more blood
available to critical organs in the chest and head. The
Trendelenburg position, though used historically, is no
longer recommended.[16]
Hypotensive shock treatment always follows the rst four
following steps. Outcomes, in terms of mortality, are directly linked to the speed that hypotension is corrected.
Still-debated methods are in parentheses, as are benchmarks for evaluating progress in correcting hypotension.
A study[17] on septic shock provided the delineation of
these general principles. However, since it focuses on hypotension due to infection, it is not applicable to all forms
of severe hypotension.

3
1. Volume resuscitation (usually with crystalloid)
2. Blood pressure support with a vasopressor (all seem
equivalent)[18]
3. Ensure adequate tissue perfusion (maintain SvO2
>70 with use of blood or dobutamine)
4. Address the underlying problem (i.e. antibiotic for
infection, stent or CABG (coronary artery bypass
graft surgery) for infarction, steroids for adrenal insuciency, etc...)

[8] Tabassum, Nahida; Feroz Ahmad (2011). Role of natural herbs in the treatment of hypertension. Pharmacognosy Review 5 (9): 3040. doi:10.4103/09737847.79097. PMC 3210006. PMID 22096316.
[9] Mitchell ES, Slettenaar M, vd Meer N, Transler C, Jans
L, Quadt F, Berry M.; Slettenaar; Vd Meer; Transler;
Jans; Quadt; Berry (2011). Dierential contributions of
theobromine and caeine on mood, psychomotor performance and blood pressure. Physiol. Behav. 104 (5):
81622. doi:10.1016/j.physbeh.2011.07.027. PMID
21839757. Theobromine ... lowered blood pressure relative to placebo

Medium-term (and less well-demonstrated) treatments of [10] William Marias Maliso (1943). Dictionary of BioChemistry and Related Subjects. Philosophical Library.
hypotension include:
pp. 311, 530, 573.

Blood sugar control (80150 by one study)

Early nutrition (by mouth or by tube to prevent ileus)
Steroid support

See also
Dysautonomia
Hypotensive transfusion reaction
Orthostatic intolerance

[11] Theobromine Chemistry Theobromine in Chocolate.

Chemistry.about.com (2013-05-12). Retrieved on 201305-30.
[12] Kelly, Caleb J (2005). Eects of theobromine should be
considered in future studies. American Journal of Clinical Nutrition 82 (2): 4867; author reply 4878. PMID
16087999.
[13] Merck Manual Home Edition. Postprandial Hypotension. Last accessed October 26, 2011.
[14] Katarzyna Konieczka, Robert Rich et al.: Flammer syndrome. EPMA Journal 2014; 5:11

[2] Diseases and Conditions Index Hypotension. National

Heart Lung and Blood Institute. September 2008. Retrieved 2008-09-16.

[15] Chobanian AV, Bakris GL, Black HR, Cushman WC,

Green LA, Izzo JL, Jones DW, Materson BJ, Oparil
S, Wright JT, Roccella EJ; Bakris; Black; Cushman; Green; Izzo Jr; Jones; Materson; Oparil;
Wright Jr; Roccella; Joint National Committee On
Prevention; National High Blood Pressure Education
Program Coordinating Committee (December 2003).
Seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. Hypertension 42 (6): 1206
52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID
14656957. Retrieved 2009-11-03.

[3] Low blood pressure (hypotension) Denition. MayoClinic.com. Mayo Foundation for Medical Education and
Research. 2009-05-23. Retrieved 2010-10-19. |rst1=
missing |last1= in Authors list (help)

[16] Kettaneh, Nicolas (30 October 2008). BestBets: Use

of the Trendelenburg Position to Improve Hemodynamics During Hypovolemic Shock. Grand Rapids Medical
Education & Research/Michigan State University.

[4] Low blood pressure (hypotension) Causes. MayoClinic.com. Mayo Foundation for Medical Education and
Research. 2009-05-23. Retrieved 2010-10-19. |rst1=
missing |last1= in Authors list (help)

[17] Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A,

Knoblich B, Peterson E, Tomlanovich M; Nguyen; Havstad; Ressler; Muzzin; Knoblich; Peterson; Tomlanovich;
Early Goal-Directed Therapy Collaborative Group (200111-08). Early goal-directed therapy in the treatment of
severe sepsis and septic shock. N Engl J Med. (NEJM)
345 (19): 136877.
doi:10.1056/NEJMoa010307.
PMID 11794169.

References

[1] TheFreeDictionary > hypotension. Citing: The American

Heritage Science Dictionary Copyright 2005

[5] Low blood pressure (hypotension)". BUPA.co.uk.

[6] What Are the Signs and Symptoms of Hypotension?".
nhlbi.nih.gov. National Institutes of Health. November 1,
2010. Retrieved 2014-02-17.
[7] Joel A. DeLisa, Bruce M. Gans, Nicholas E. Walsh (editors) (2005). 19. Physical Medicine and Rehabilitation:
Principles and Practice 1. Lippincott Williams & Wilkins.
p. 468.

[18] Havel, C; Arrich, J; Losert, H; Gamper, G; Mllner, M;

Herkner, H (2011-05-11). Herkner, Harald, ed. Vasopressors for hypotensive shock. Cochrane database
of systematic reviews (Online) 5 (5): CD003709.
doi:10.1002/14651858.CD003709.pub3.
PMID
21563137.

External links
Understanding Low Blood Pressure the Basics
WebMD
Hypotension PubMed Health

EXTERNAL LINKS

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