An 87-year-old man is admitted to the hospital following a fall at home. He says that he stood up quickly to answer the telephone, then felt dizzy and subsequently blacked out. His wife saw what happened; she said he just fell to the floor but made a quick recovery. He did not injure himself, but she was unable to get him off the floor so she called emergency medical services. He has had several similar episodes of dizziness at home when walking around the house but has not previously passed out. He denies chest discomfort, palpitations, shortness of breath, or diaphoresis accompanying the dizzy episodes.
He was recently discharged from the hospital after a 5-day admission for poor oral intake and weakness and has been gradually regaining strength at home. His past medical history is notable for paroxysmal atrial fibrillation, type 2 diabetes mellitus (DM), hypertension, benign prostate hypertrophy (BPH), and heart failure (HF) with preserved ejection fraction. He takes metformin 850 mg BID, losartan 25 mg daily, metoprolol succinate 25 mg daily, apixaban 5 mg BID, furosemide 40 mg daily, and tamsulosin 0.4 mg daily (started during his recent hospitalization).
Clinical examination reveals a regular rate and rhythm, clear lungs, no jugular venous distention, and trace ankle edema. He has already taken all his morning medications today. His blood pressure (BP) is 158/55 mm Hg with heart rate (HR) 74 bpm while supine and 122/60 mm Hg with HR 89 bpm within 3 min of standing. Electrocardiography shows normal sinus rhythm with first-degree atrioventricular block. Other intervals are normal. Bloodwork is notable for creatinine 1.2 mg/dL (consistent with his baseline) and hemoglobin 12.9 g/dL.
Which one of the following is the appropriate next step in management?
Show Answer
The correct answer is: D. Stop tamsulosin and re-evaluate furosemide dose.
Answer choice A is an incorrect choice. Addition of midodrine would effectively increase standing BP and may reduce risk of future syncopal events; however, it is not the best option in this patient due to the potential to increase supine BP (the patient already has inadequately controlled hypertension). In addition, midodrine can cause urinary retention and would not be ideal in this patient who already requires tamsulosin for BPH.1-4
Answer choice B is an incorrect choice. Fludrocortisone can increase plasma volume and thus can improve symptoms of orthostatic hypotension (OH); however, this is not the best option in this patient due to his already inadequately controlled BP and history of HF with preserved ejection fraction.5
Answer choice C is an incorrect choice. Increased salt ingestion can increase plasma volume; however, it would not be beneficial in this patient with a history of hypertension, renal disease, and HF. In addition, the long-term effects of these treatments, including the benefits and risks, are unknown.6
Answer choice D is the correct choice. The patient has OH resulting in recurrent presyncope and now, syncope. His BP drops by >20 mm Hg with assumption of an upright position. He has a blunted HR response due to metoprolol use. The OH is likely multifactorial in the setting of longstanding DM (resulting in some degree of neurogenic OH) as well as medication related (tamsulosin, furosemide). Tamsulosin can cause OH in the first few weeks after initiation. The best option for this patient is to discontinue tamsulosin. In addition, the furosemide dose should be re-assessed, and dose reduction should be considered.7,8
Educational grant support provided by: Medtronic
To visit the course page for the Assessment and Diagnosis of Syncope Project, click here!
References
Blake AJ, Morgan K, Bendall MJ, et al. Falls by elderly people at home: prevalence and associated factors. Age Ageing 1988;17:365-72.
Burke V, Beilin LJ, German R, et al. Postural fall in blood pressure in the elderly in relation to drug treatment and other lifestyle factors. Q J Med 1992;84:583-91.
Fouad-Tarazi FM, Okabe M, Goren H. Alpha sympathomimetic treatment of autonomic insufficiency with orthostatic hypotension. Am J Med 1995;99:604-10.
Jankovic J, Gilden JL, Hiner BC, et al. Neurogenic orthostatic hypotension: a double-blind, placebo-controlled study with midodrine. Am J Med 1993;95:38-48.
Campbell IW, Ewing DJ, Clarke BF. 9-Alpha-fluorohydrocortisone in the treatment of postural hypotension in diabetic autonomic neuropathy. Diabetes 1975;24:381-4.
El-Sayed H, Hainsworth R. Salt supplement increases plasma volume and orthostatic tolerance in patients with unexplained syncope. Heart 1996;75:134-40.
Beckett NS, Connor M, Sadler JD, Fletcher AE, Bulpitt CJ. Orthostatic fall in blood pressure in the very elderly hypertensive: results from the hypertension in the very elderly trial (HYVET) - pilot. J Hum Hypertens 1999;13:839-40.
Fotherby MD, Potter JF. Orthostatic hypotension and anti-hypertensive therapy in the elderly. Postgrad Med J 1994;70:878-81.
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