324 Therapy of Selected Diseases
Acute hypotension. Failure of orthostatic
‡ Hypotension
The venous side of the circulation accom-
modates ~ 85% of the total blood volume;
because of the low venous pressure (mean
~ 15 mmHg), it is referred to as the low-pres-
sure system. The arterial vascular beds, rep-
resenting the high-pressure system (mean
pressure ~ 100 mmHg), contain ~ 15%. The
arterial pressure generates the driving force
for perfusion of tissues and organs. Blood
draining from these collects in the low-pres-
sure system and is pumped back by the heart
into the high-pressure system.
The arterial blood pressure (ABP) depends
on: (1) the volume of blood per unit of time
that is forced by the heart into the high-
pressure system—cardiac output corre-
sponding to the product of stroke volume
and heart rate (beats/min), stroke volume
being determined by, inter alia, venous fill-
ing pressure; (2) the counterforce opposing
the flow of blood, i. e., peripheral resistance,
which is a function of arteriolar caliber.
Chronic hypotension (recumbent systolic BP
< 105 mmHg). Primary idiopathic hypoten-
sion generally has no clinical importance. If
symptoms such as lassitude and dizziness
occur, a program of physical exercise instead
of drugs is advisable.
Secondary hypotension is a sign of an
underlying disease that should be treated
first. If stroke volume is too low, as in heart
failure, a cardiac glycoside can be given to
increase myocardial contractility and stroke
volume. When stroke volume is decreased
owing to insuf cient blood volume, plasma
substitutes will be helpful in treating blood
loss, whereas aldosterone deficiency re-
quires administration of a mineralocorticoid
(e. g., fludrocortisone). The latter is the drug
of choice for orthostatic hypotension due to
autonomic failure. A parasympatholytic (or
electrical pacemaker) can restore cardiac
rate in bradycardia.
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regulation. A change from the recumbent to
the erect position (orthostasis) will cause
blood within the low-pressure system to
sink toward the feet because the veins in
body parts below the heart will be dis-
tended, despite a reflex venoconstriction,
by the weight of the column of blood in the
blood vessels. The fall in stroke volume is
partly compensated by a rise in heart rate.
The remaining reduction of cardiac output
can be countered by elevating the peripheral
resistance, enabling blood pressure and or-
gan perfusion to be maintained. An ortho-
static malfunction is present when counter-
regulation fails and cerebral blood flow falls,
with resultant symptoms, such as dizziness,
“black-out,” or even loss of consciousness. In
the sympathotonic form, sympathetically-
mediated circulatory reflexes are intensified
(more pronounced tachycardia and rise in
peripheral resistance, i. e., diastolic pres-
sure); however, there is failure to compen-
sate for the reduction in venous return. Pro-
phylactic treatment with sympathomimetics
would therefore hold little promise. Instead,
cardiovascular fitness training would appear
more important. An increase in venous re-
turn may be achieved in two ways. Increas-
ing NaCl intake augments salt and fluid re-
serves and, hence, the blood volume (contra-
indications: hypertension, heart failure).
Constriction of venous capacitance vessels
might be produced by dihydroergotamine.
Whether this effect could also be achieved
by an α-sympathomimetic, remains debat-
able. In the very rare asympathotonic form,
use of sympathomimetics would certainly be
reasonable.
 Hypotension 325

A. Treatment of hypotension

Low-pressure High-pressure
system system
Brain

Lung

β-Sympathomimetics
Cardiac Parasym-
glycosides patholytics

Venous
return
Stroke vol. x rate
Heart = cardiac output

Blood pressure (BP)

Kidney

Peripheral resistance

Intestines

Arteriolar α-Sympatho-
caliber mimetics

Skeletal muscle
Initial condition Increase of blood volume

0.9%
SA
LT

NaCl
BP
NaCl + H2O
BP

Redistribution of blood volume NaCl

+ H 2O
BP

Constriction of venous capacitance

vessels, e.g., dihydroergotamine if Mineralo-
appropriate, α-sympathomimetics corticoid

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All rights reserved. Usage subject to terms and conditions of license.