Orthostatic Disorders of the Circulation: Mechanisms, Manifestations, and Treatment

276 Pages·1987·8.19 MB·English

by  David H. P. Streeten M.B.

Orthostatic
Disorders of
the Circulation
MECHANISMS, MANIFESTATIONS,
AND TREATMENT
Orthostatic
Disorders of
the Ci rcu lation
MECHANISMS, MANIFESTATIONS,
AND TREATMENT
David H. P. Streeten,
M.B., B.Ch., O.Phi., F.R.C.P., F.A.C.P.
Professor of Medicine
and Chief of Endocrine Section
State University of New York Health Science Center
Syracuse, New York
PLENUM MEDICAL BOOK COMPANY
New York and London
Library of Congress Cataloging in Publication Data
Streeten, David H. P., 1921-
Orthostatic disorders of the circulation.
Bibliography: p.
Includes index.
I. Hypotension, Orthostatic-Complications and sequelae. 2. Edema. 3. Blood
pressure-Regulation. I. Title. [DNLM: I. Blood Circulation. 2. Edema
physiopathology. 3. Hypotension, Orthostatic-physiopathology. 4. Posture. QZ 170
S9150)
RC685.078S87 1986 616.1 86-18748
ISBN 978-1-4684-8964-4 ISBN 978-1-4684-8962-0 (eBook)
DOl 10.1007/978-1-4684-8962-0
© 1987 Plenum Publishing Corporation
Softcover reprint of the hardcover 1s t edition 1987
233 Spring Street, New York, N.Y. 10013
Plenum Medical Book Company is an imprint of Plenum Publishing Corporation
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
This book is dedicated to my wife, Barbara, who
encouraged me to prepare the manuscript, and to clinical
investigators in all lands, who seek to alleviate illness and
suffering by studying the underlying derangements of
physiological processes.
Preface
Most of us spend at least two-thirds of our lives either sitting or standing. It is
somewhat surprising, therefore, to find not a single book devoted to disorders
caused by derangements of the normal physiological adjustments to changes in
posture. In fact, until very recently, medical students have not even been advised
to measure the blood pressure and heart rate in the upright posture as part of the
routine physical examination. Although Bradbury and Eggleston first described
orthostatic hypotension as a consequence of autonomic insufficiency in 1925,
interest in orthostatic disorders has been slow to develop in the subsequent years.
It is well known that the change from recumbency to the standing posture
stimulates neurological, endocrine, and cardiovascular adjustments that ensure
maintenance of a normal circulation despite the effects of gravitational forces.
The mechanisms of these physiological responses to orthostasis have been stud
ied by many investigators. Some of the defects to which antigravitational com
pensatory mechanisms are subject, such as postural hypotension resulting from
autonomic failure, have been studied intensively and have become part of the
general knowledge of most medical practitioners. Other orthostatic disorders
such as various other postural abnormalities of blood pressure control, and
orthostatic edema-have received far less attention and have been unable to
compete with the more dramatic and life-threatening ailments of humankind for a
place in our standard medical texts. These disorders often give rise to distressing
symptoms and may lead to severe impairment of health. Since they do not appear
to have been described and discussed systematically before, I have attempted in
the present volume to collate our own studies performed over the past 30 years,
as well as those reported by others, on the pathogenesis, clinical manifestations,
and treatment of these and other postural disorders of the circulation.
ACKNOWLEDGMENTS
In this endeavor, I have enjoyed the constant stimulation of colleagues in
the Endocrine Section of the Department of Medicine, especially Dr. Arnold
vii
viii PREFACE
Moses, Dr. Gunnar Anderson, Jr., Dr. Stanley Blumenthal, and Dr. Myron
Miller, as well as participants in our interdepartmental Endocrine Study Group at
the State University of New York Health Science Center at Syracuse, particularly
Drs. Jay and Helen Tepperman and Dr. Robert Richman. Dr. Howland
Auchincloss, Jr., Dr. Harold Smulyan, Dr. Anis Obeid, Dr. Robert Eich, Dr.
Deaver Thomas, and Dr. Robert Richardson have made valuable contributions to
the investigations. The studies have been performed in collaboration with a series
of research fellows, particularly Dr. Philip Speller, Dr. Theodore Dalakos, Dr.
Gunnar Anderson, Jr., Dr. Michael Freiberg, and Dr. Timothy Howland, to all
of whom it is a pleasure to acknowledge my profound indebtedness.
A succession of keen and inquisitive medical students has participated in the
performance and discussion of the clinical experiments. The studies could not
have been undertaken without the devoted and careful assistance of the nurses
and dietitians at our Clinical Research Center or the skillful biochemical analyses
performed by our technicians in the Endocrine Research Laboratory: Mary Kear
ney, Thomas Scullard, Carol Jones, and Suzanne Brennan. Suzanne Brennan
and David Peppi were responsible for preparing most of the diagrams and the
photographs were taken by the Photography Department of the SUNY Health
Science Center. To all these collaborators I offer my sincere thanks.
The United States Public Health Service supported a large number of the
investigations on which much of this book is based, with grants RR 229, A 3795,
AM 04488, AM 07793, HL 14076, and HL 2205l.
Last but not least, I am very grateful to the patients who have cheerfully
endured the discomfort involved in so many of the studies described in this book.
I believe they have understood that virtually no advance in alleviating human
disorders can be achieved without studies on some of the sufferers themselves,
and I sincerely hope that most have derived some therapeutic benefit from the
results of these investigations.
David H. P. Streeten
Syracuse, New York
Contents
Chapter 1
PHYSIOLOGY OF THE MICROCIRCULATION
1.1. Control of the Peripheral Vasculature ........................ .
1.1.1. Sympathetic Innervation ............................... 1
1.1.2. Humoral Agents and Local Tissue Metabolites ............. 3
1.2. Physiological Requirements Imposed by Orthostasis . . . . . . . . . . . .. 4
1.3. Orthostatic Circulatory Adjustments: Neurohumoral Mechanisms .. 5
1.3.1. Catecholamine Responses .............................. 5
1.3.2. Changes in the Renin-Angiotensin-Aldosterone System ...... 8
1.3.3. Other Physiological Changes in the Erect Posture. . . . . . . . . .. 9
1.4. Disorders of the Peripheral Circulation ....................... 10
1.5. Orthostatic Disorders of the Circulation. . . . . . . . . . . . . . . . . . . . . .. 11
1.6. Summary ............................................... 11
Chapter 2
ORTHOSTATIC EDEMA: DEFINITION AND PATHOGENESiS ....... 13
2.1. Definition of Orthostatic Edema ............................. 13
2.2. General Mechanisms of Edema Formation. . . . . . . . . . . . . . . . . . . .. 14
2.2.1. Increased Capillary Hydrostatic Pressure .................. 14
2.2.2. Reduced Plasma Protein Oncotic Pressure ................. 16
2.2.3. Pathologically Leaky Capillaries. . . . . . . . . . . . . . . . . . . . . . . .. 16
2.2.4. Tissue Pressure Changes ............................... 16
2.2.5. Lymphatic Obstruction ................................ 16
2.3. Pathogenesis of Orthostatic Edema. . . . . . . . . . . . . . . . . . . . . . . . . .. 16
2.3.1. Role of Posture in the Pathogenesis of Edema ............. 16
2.3.2. Mechanisms of Orthostasis-Induced Fluid Retention. . . . . . . .. 22
ix
x CONTENTS
2.3.3. Summary of Pathogenesis .............................. 41
2.3.4. How Does Orthostasis Trigger the Abnormal Responses in
Patients with Orthostatic Sodium Retention? ............... 42
2.3.5. Cause of Excessive Orthostatic Intravascular Pooling ........ 49
2.4. Summary ............................................... 56
Chapter 3
ORTHOSTATIC EDEMA: CLINICAL FEATURES .................... 59
3.1. Gender, Age, and Prevalence ............................... 59
3.1.1. In Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 59
3.1.2. In Men ............................................. 59
3.1.3. Age of Onset ........................................ 60
3.1.4. Distribution and Prevalence. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 61
3.2. Symptoms and Signs ...................................... 61
3.2.1. Evidence of Fluid Accumulation. . . . . . . . . . . . . . . . . . . . . . . .. 61
3.2.2. Nocturia ............................................ 65
3.2.3. Symptoms Resulting from the Edema .................... 66
3.2.4. Intracranial Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 67
3.2.5. Cardiovascular Features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 69
3.2.6. Other Clinical Features ................................ 72
3.3. Factors That Aggravate Orthostatic Edema .................... 73
3.3.1. Menstruation......................................... 73
3.3.2. Oral Estrogen Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 74
3.3.3. Pregnancy........................................... 74
3.3.4. Environmental Heat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 74
3.4. Laboratory Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 75
3.5. Summary ............................................... 75
Chapter 4
ORTHOSTATIC EDEMA: DIAGNOSiS ............................ 77
4.1. Exclusion of Known Types of Edema ........................ 77
4.1.1. Congestive Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 77
4.1.2. Renal Edema ........................................ 78
4.1.3. Hepatic Disease ...................................... 79
4.1.4. Other Generalized Disorders ............................ 79
4.1.5. Local Causes of Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83
4.1.6. Capillary Leak Syndrome .............................. 83
CONTENTS xi
4.2. Positive Diagnosis of Orthostatic Edema ...................... 83
4.2.1. History ............................................. 83
4.2.2. Screening Test ....................................... 84
4.2.3. Definitive Tests ...................................... 84
4.3. Summary ............................................... 88
Chapter 5
ORTHOSTATIC EDEMA: TREATMENT AND PROGNOSIS ...... .... 91
5.1. General Aspects ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 91
5.2. Control of Posture ........................................ 92
5.3. Dietary and Fluid Restrictions ............................... 92
5.4. Conventional Diuretics .................................... 93
5.5. Treatment of Potassium Depletion ........................... 93
5.5.1. Potassium-Sparing Diuretics ............................ 94
5.5.2. Potassium Supplements ................................ 96
5.6. Elastic Garments and Stockings ............................. 97
5.7. Dopamine Agonists ....................................... 98
5.8. Converting Enzyme Inhibitors: Captopril .. . . . . . . . . . . . . . . . . . . .. 98
5.9. Vasoconstrictors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 99
5.9.1. Ephedrine ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 99
5.9.2. Amphetamines ....................................... 101
5.9.3. Midodrine ........................................... 101
5.9.4. Mechanism of Action of Vasoconstrictors in Orthostatic
Edema .............................................. 105
5.9.5. Side Effects of Sympathomimet,c Amines ................. 106
5.9.6. Long-Term Administration of Sympathomimetic Agents ..... 108
5.10. Summary of Therapeutic Program ........................... 108
5.11. Summary ............................................... 109
Chapter 6
ORTHOSTATIC DISORDERS OF BLOOD PRESSURE CONTROL:
DEFINITIONS AND CLASSIFICA TlON ............................ 111
6.1. Technique of Blood Pressure Measurement in the Upright Posture 111
6.2. Orthostatic Blood Pressure and Heart Rate Changes: Normal
Limits .................................................. 116
6.3. Definable Disorders of Blood Pressure and Heart Rate Control .... 118
6.3.1. Orthostatic Arterial Anemia ............................ 119
6.3.2. Neurocirculatory Asthenia .............................. 120
xii CONTENTS
6.4. Classification of Orthostatic Disorders of Blood Pressure Control .. 121
6.4.1. Role of the Autonomic Nervous System .................. 121
6.4.2. Heart Rate Changes ................................... 122
6.4.3. Effects of Adrenocortical Insufficiency ................... 123
6.4.4. Excessive Orthostatic Rise in Diastolic Blood Pressure ...... 123
6.4.5. Types of Orthostatic Blood Pressure Disorders ............. 124
6.5. Summary ............................................... 125
Chapter 7
ORTHOSTATIC DISORDERS OF BLOOD PRESSURE CONTROL:
PATHOGENESIS .............................................. 127
7.1. Orthostatic Hypotension ................................... 127
7.1.1. Autonomic Insufficiency ............................... 128
7.1.2. Hyperadrenergic Postural Hypotension .................... 130
7.2. Orthostatic Hypertension and Other Types of Orthostatic Blood
Pressure Disorders ........................................ 131
7.3. Causes of Orthostatic Blood Pressure Disorders ................ 132
7.4. Pathogenesis of Orthostatic Blood Pressure Disorders Associated
with Intact Autonomic Function ............................. 135
7.4.1. Effects of Changes in Blood Volume Induced by Venesection 135
7.4.2. Evidence of Excessive Gravitational Pooling of Blood ....... 143
7.4.3. Effects of Posture on Cardiac Filling ..................... 155
7.4.4. Effects of Posture on Cardiac Output ..................... 157
7.4.5. Postural Changes in Plasma Norepinephrine Concentration ... 159
7.4.6. Blood Kinin Concentration ............................. 161
7.4.7. Potential Role of Insulin ............................... 166
7.5. Conclusions ............................................. 166
7.6. Summary ............................................... 171
Chapter 8
ORTHOSTATIC DISORDERS OF BLOOD PRESSURE CONTROL:
CLINICAL FEATURES .......................................... 173
8.1. Frequency of Main Symptoms .............................. 173
8.2. Intracranial Features ....................................... 173
8.2.1. Lightheadedness and Blurred Vision .................... 173
8.2.2. Syncope ........................................... 177
8.2.3. Convulsive Seizures ................................. 177
8.2.4. Orthostatic Hemiplegia ............................... 177