Transient Hypotension in an Elderly Hypertensive Patient

Objective: A 60 year old hypertensive female presented to the office with fatigue and pre syncope lasting for 6 hours after a home blood pressure reading showed her systolic was 60. This happened several times a week. A 24 hr ABP was done & the patient woke up early hours feeling terrible & her SBP was below 70 mm Hg & the 24 hr ABP which showed 2 hypotensive readings between 6 and 7am. The BP came up slowly in a few hours & she recovered several hours later. Design and method: The patient was originally on Ramipril for hypertension prescribed by a local cardiologist, and then Nifedipine was added. Both short acting agents. She got these attacks weekly. She was switched over to long acting Perindopril & Amlodipine taken 12 hours apart. The frequency of the attacks reduced considerably to less than one per month. There was no orthostatic drop in pressure or any relationship to meals or exercise. Results: Systolic blood pressure below 70mmHg can lead to reduced perfusion to the brain. Low SBP can present as symptoms or manifestations of decreased cardiac or cerebrovascular circulation. It is important to differentiate orthostatic and postprandial hypotension from this transient cause. It is still unclear if the probability of organ damage is the same in symptomatic vs asymptomatic patients. Some patients have short term, or transient, symptomatic hypotension that has an poor prognosis. Conclusions: Managing hypertension in elderly is a challenge & must take into consideration to avoid orthostatic hypotension. It is important to do ambulatory monitoring on them to be able to register symptomatic episode. In this situation the drop in pressure was not Orthostatic or Post prandial. The mechanism is not easily explained but cases have been documented and in patients complaining of fatigue & Presyncope or Syncope, ambulatory monitoring is the key. When treating hypertension in elderly patients, the goal of treatment should not be to meet target but treating to lowest level tolerated without causing hypotension. A med review should be done to optimize on the class of drugs being taken.