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POSTURAL HYPOTENSION — THE GREAT DECEIVERArticles - Dr. Bernstein Shares His Insights Your patients are dizzy and feel faint after the get up from the couch is it Postural Hypotension or is it Hypoglycemia? Richard K. Bernstein, M.D., F.A.C.E., F.A.C.N., FCCWS, lets us know how we can avoid getting deceived.Diabetes Solution Revised and Updated 2007
POSTURAL HYPOTENSION —
Syncope, or fainting, is fairly common as people get older. It is especially common among diabetics. Even more common is near-syncope. This is merely the feeling that you will pass out unless you lie down right away. Simultaneously, your surroundings may look gray or your vision may fade. There are many causes of syncope and near-syncope. These include cardiac and neurological problems, certain medications, and dehydration. These causes are not nearly as common in diabetics as are sudden drops of blood pressure caused by autonomic neuropathy or by inappropriate use of antihypertensive medications—especially diuretics (“water pills”) and alpha-1 adrenergic antagonists, such as prazosin and terazosin. When most of us stand from a seated, supine, or squatting position, the brain sends a message to the blood vessels in our legs to constrict reflexively and instantly. This prevents blood from pooling in the legs, which would deprive the brain of blood and oxygen. If you’ve had high blood sugars for many years, the nerves that signal the vessels in the legs may conduct the message poorly (a sign of autonomic neuropathy). A drop in blood pressure upon standing, called postural, or orthostatic, hypotension, occurs when this pooling in the legs occurs. For some, the heart may bring blood pressure back up by increasing its rate and amount of contraction. Unfortunately, this does not occur for many diabetics with autonomic neuropathy. Alternatively, if you eat a big meal, blood may concentrate in your digestive system, also depriving the brain. The normal mechanisms that protect the brain from this shunting of blood may be deficient if you have autonomic neuropathy. It is in part to gauge potential for these reactions that I measure supine and standing blood pressures, and perform R-R interval studies on all my diabetic patients. A recent study of medical (mostly nondiabetic) outpatients in the United States suggests that 20 percent of individuals over the age of 65 and 30 percent of those over age 70 have documentable postural hypotension. For diabetics the incidence is probably much greater. A common scenario for syncope or near-syncope involves the diabetic who gets up in the middle of the night to urinate and keels over on the way to the bathroom. A simple way to avoid this is to sit at the edge of the bed with feet dangling for a few minutes before standing. Another syncope scenario involves the person who goes to the toilet and passes out while trying to produce a bowel movement or urinate. Again, the reflexes that prevent shunting of blood away from the brain are blunted by autonomic neuropathy. If syncope is caused by transient low cerebral blood pressure as a result of autonomic neuropathy, one should lay the victim out flat and elevate his feet high above his head. He should return to consciousness almost immediately. The symptoms of syncope are similar to those of moderate to severe hypoglycemia. In both cases, the brain is being deprived of a basic nutrient—oxygen in the case of syncope, glucose in the case of hypoglycemia. Furthermore, postural hypotension can also occur as a result of hypoglycemia. Some symptoms of near-syncope include faintness, visual changes, and disorientation. Whatever the cause of fainting or near-syncope, blood sugar must be checked to rule out hypoglycemia. If blood sugar is normal, no amount of glucose will cure the problem. People with recurrent postural hypotension will usually find relief by wearing surgical stockings of 30–40 mm compression. If these are inadequate, waist-high surgical pantyhose should be used Next FREE LIVE WEBCAST: Wednesday, January 16, 2007, we wll be having another live webcast and teleconference call with Dr. Richard K. Bernstein, who will answer questions from medical professionals and patients and it is free. Just go to www.diabetes911.net and register and ask a question if you like!
Also available a 5CD-6hour education series by Dr. Richard K. Bernstein: ORDER NOW!! www.diabetes911.net ALSO CHECK OUT Dr. Bernstein’s new site with all of his videos features and teleconference calls.
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Chapter 20
We would like to thank the publisher Little Brown and Company and Dr. Richard K. Bernstein, for allowing us to provide excerpts from Diabetes Solution 2007 Edition
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