John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Conditions that reduce the volume of blood, reduce cardiac output (the amount of blood pumped by the heart), and medications are frequent
reasons for low blood pressure.
Dehydration is common among patients with prolonged
nausea,
vomiting, and
diarrhea. Large amounts
of water are lost when vomiting and with diarrhea, especially if the person
does not drink adequate amounts of fluid to replace the depleted water.
Other causes of dehydration include exercise, sweating,
fever, and
heat exhaustion, or
heat stroke. Individuals with mild dehydration may experience only thirst and
dry mouth. Moderate to severe dehydration may cause orthostatic hypotension (manifested
by lightheadedness, dizziness, or fainting upon standing). Prolonged and severe dehydration can lead to shock,
kidney failure,
confusion,
acidosis (too much acid in the blood),
coma, and even death.
Moderate or severe bleeding can quickly deplete an individual's body of blood, leading to low blood pressure or orthostatic hypotension. Bleeding can result from trauma, surgical complications, or from gastrointestinal abnormalities such as
ulcers, tumors, or
diverticulosis. Occasionally, the bleeding may be so severe and rapid (for example, bleeding from a ruptured
aortic aneurysm) that it causes shock and death rapidly.
Severe inflammation of organs inside the body such as acute pancreatitis can cause low blood pressure. In acute pancreatitis, fluid leaves the blood vessels to enter the inflamed tissues around the pancreas as well as the abdominal cavity,
concentrating blood and reducing its volume.
Causes of low blood pressure due to heart disease
Weakened heart muscle can cause the heart to fail and reduce the amount of blood it pumps. One common cause of weakened heart muscle is the death of a large portion of the heart's muscle due to a single, large heart attack or repeated smaller heart attacks. Other examples of conditions that can weaken the
ability of the heart to pump blood include medications that are toxic to the heart, infections of the muscle of the heart by viruses (myocarditis), and diseases of the heart's valves such as aortic stenosis.
Pericarditis is an inflammation of the pericardium (the sac surrounding the heart). Pericarditis can cause fluid to accumulate within the pericardium and compress the heart, restricting the ability of the heart to fill and pump blood.
Pulmonary embolism is a
condition in which a blood clot in a vein (deep vein thrombosis) breaks off and travels to the heart and eventually the lung. A large blood clot can block the flow of blood into the left ventricle from the lungs and severely diminish the blood returning to the heart for pumping.
Pulmonary embolism is a life-threatening emergency.
A slow heart rate (bradycardia) can decrease the amount of blood pumped by the heart. The resting heart rate for a healthy adult is between 60 and 100 beats/minute.
Bradycardia (resting heart rates slower than 60 beats/minute) does not always cause low blood pressure. In fact, some highly trained athletes can have resting heart rates in the 40s and 50s
(beats per minute) without any symptoms. (The slow heart rates are
offset by more forceful contractions of the heart that pump more blood
than in non-athletes.) But in many patients bradycardia can lead to low
blood pressure, lightheadedness, dizziness, and even fainting.
Several common reasons for bradycardia include: 1) sick sinus syndrome,
2) heart block, and 3) drug toxicity. Many of these conditions occur in the elderly.
Sick sinus syndrome: Sick sinus syndrome occurs when the diseased electrical system of the heart cannot generate signals fast enough to maintain a normal heart rate.
Heart block: Heart block occurs when the specialized tissues that transmit electrical current in the heart are damaged by heart attacks, degeneration from atherosclerosis, and medications. Heart block prevents some or all of the electrical signals from reaching
parts of the heart, and this prevents the heart from contracting as
well as it otherwise would.
Drug toxicity: Drugs such as digoxin
(Lanoxin) or beta blockers for high blood pressure, can slow the transmission of electricity in the heart chemically and can cause bradycardia and hypotension (see section below "Medications that cause low blood pressure").
An abnormally fast heart rate (tachycardia) also can cause low blood pressure. The most common example of
tachycardia causing low blood pressure is atrial fibrillation. Atrial fibrillation is a disorder of the heart characterized by rapid and irregular electrical discharges from the muscle of the heart causing the ventricles to contract irregularly and (usually) rapidly. The rapidly contracting ventricles do not have enough time to fill maximally with blood before the each contraction, and the amount of blood that is pumped decreases in spite of the faster heart rate. Other abnormally rapid heart rhythms such as ventricular tachycardia also can produce low blood pressure, sometimes even life-threatening shock.
Medications that cause low blood pressure
Medications such as calcium channel blockers, beta blockers, and digoxin (Lanoxin) can slow the rate at which the heart contracts. Some elderly people are extremely sensitive to these medications since they are more likely to have diseased hearts and electrical conduction tissues. In some individuals, the heart rate can become dangerously slow even with small doses of these medications.
Medications used in treating high blood pressure
(such as ACE inhibitors,
angiotensin receptor blockers, beta blockers, calcium
channel blockers, and alpha-blockers) can excessively lower blood pressure and
result in symptomatic
low blood pressure especially among the elderly.
Water pills (diuretics) such as
hydrochlorothiazide furosemide (Lasix) can decrease blood volume
by causing excessive urination.
Alcohol and narcotics also can cause low blood pressure.
Other conditions that cause low blood pressure
Vasovagal reaction is a common condition in which a healthy person temporarily develops low blood pressure, slow heart rate, and sometimes fainting. A vasovagal reaction typically is brought on by emotions of fear or pain such as having blood drawn, starting an intravenous infusion, or by gastrointestinal upset. Vasovagal reactions are caused by activity of
the involuntary (autonomic) nervous system, especially the
vagus nerve, which releases hormones that slow the heart and widen the blood vessels. The vagus nerve also controls digestive tract function and senses activity in
the digestive system. Thus, some people can have a vasovagal reaction from straining at a bowel movement or
vomiting.
Postural (orthostatic) hypotension is a sudden drop in blood pressure when an individual stands up from a sitting, squatting, or supine (lying) position. When a person stands up, gravity causes blood to settle in the veins in the legs so that less blood returns to the heart for pumping, and, as a result, the blood pressure drops. The body normally responds automatically to the drop in blood pressure by increasing the rate at which the heart beats and by narrowing the veins to return more blood to the heart. In patients with
postural hypotension, this compensating reflex fails to occur, resulting low blood pressure and its symptoms. Postural hypotension can occur in persons of all ages but is much more common among the elderly, especially in those on medications for high blood pressure and/or diuretics. Other causes of postural hypotension include dehydration, adrenal insufficiency (discussed later), prolonged bed rest,
diabetes that has caused damage to the autonomic nerves,
alcoholism with damage to the autonomic nerves, and certain rare neurological syndromes (for example,
Shy-Drager syndrome) that damage the autonomic
nerves.
Another form of postural hypotension occurs typically in young healthy
individuals. After prolonged standing, the individual's heart rate and blood
pressure drop, causing dizziness, nausea, and often fainting. In these
individuals, the autonomic nervous system wrongly responds to prolonged standing
by directing the heart to slow down and the veins to dilate.
Micturition syncope is a temporary drop in blood pressure and loss of
consciousness brought about by urinating. This condition typically occurs in
elderly patients and may be due to the release by the autonomic nerves of
hormones that lower blood pressure.
Adrenal insufficiency, for example, due to
Addison's disease, can cause low
blood pressure. Addison's disease is a disorder in which the adrenal glands
(small glands next to the kidneys) are destroyed. The destroyed adrenal glands
can no longer produce sufficient adrenal hormones (specifically cortisol)
necessary to maintain normal bodily functions. Cortisol has many functions,
one of which is to maintain blood pressure and the function of the heart.
Addison's disease is characterized by weight loss, muscle weakness, fatigue, low blood
pressure, and, sometimes, darkening of the skin.
Septicemia is a
severe infection in which bacteria (or other infectious
organisms such as fungi) enter the blood. The infection typically originates in
the lungs (as pneumonia),
bladder, or in the abdomen due to
diverticulitis or
gallstones. The bacteria then enter the blood where they
release toxins and cause life-threatening and profound low blood pressure
(septic shock),
often
with damage to several organs.
Anaphylaxis (anaphylactic
shock) is a potentially fatal allergic reaction to
medications such as penicillin, intravenous iodine used in some
X-ray studies,
foods such as peanuts, or
bee stings (insect
stings). In addition to a severe drop in blood pressure, individuals may also experience
hives as well as wheezing due to constriction of the airways, and a swollen throat which cause difficulty breathing. The shock is caused by enlargement of blood-containing blood vessels and escape of water from the blood into the tissues.
Kidney failure can occur from an acute event or a chronic condition or disease. Prerenal kidney failure is caused by blood loss, dehydration, medication. Some of the renal causes of kidney failure are from sepsis, medications, rhabdomyolysis, multiple myeloma, and acute glomerulonephritis. Post renal causes of kidney failure include bladder obstruction, prostate problems, tumors, or kidney stones. Treatment options included diet, medications, or dialysis.
Diverticulitis is a condition in which diverticuli in the colon rupture. The rupture results in infection in the tissues that surround the colon. Diverticulitis symptoms include: abdominal pain, abdominal cramps, diarrhea, constipation, and bloating. Treatment methods include prescription medications, and in some cases, diverticulitis surgery.
Dehydration is the excessive loss of body water. There are a number of causes of dehydration including heat exposure, prolonged vigorous exercise, and some diseases of the gastrointestinal tract. The best way to treat dehydration is to prevent it from occurring.
Dizziness is a symptom that is often applies to a variety of sensations including lightheadedness and vertigo. Causes of dizziness include low blood pressure, heart problems, anemia, dehydration, and more. Treatment of dizziness depends on the cause.
A pulmonary embolism occurs when a piece of a blood clot from deep vein thrombosis (DVT) breaks off and travels to an artery in the lung where it blocks the artery and damages the lung. The most common symptoms of a pulmonary embolism are shortness of breath, chest pain, and a rapid heart rate.
Deep vein thrombosis (DVT) is a blood clot in a vein located deep in the muscles of the legs, thighs, pelvis (lower torso), or arms. The most common symptoms of a deep vein thrombosis are swelling and pain in the leg that has the blood clot. A DVT is difficult to diagnose without specific tests in which the deep vein system can be examined.
Angina is chest pain that is due to an inadequate supply of oxygen to the heart muscle.
Angina can be caused by coronary artery disease or spasm of the coronary
arteries. EKG, exercise treadmill, stress echocardiography, stress thallium, and cardiac
catheterization are important tests used in the diagnosis of angina.
Dengue fever is contracted from the bite of a striped Aedes aegypti mosquito. Symptoms of dengue include headache, fever, exhaustion, severe joint and muscle pain, rash, and swollen glands. Since dengue is caused by a virus, there is no specific medicine to treat it. Treatment instead focuses on relieving the symptoms.
Pancreatitis is a rare disease in which the pancreas becomes inflamed, occurring when digestive enzymes are activated and begin attacking the pancreas causing damage to the gland. There are two types of pancreatitis, acute and chronic. Most commonly caused by alcohol or gallstones, it can lead to bleeding in the gland, serious tissue damage, infection, and cysts. Enzymes and toxins may then enter the bloodstream and seriously injure organs, such as the heart, lungs, and kidney.
Fainting, also referred to as blacking out, syncope, or temporary loss of consciousness has many causes. Often a person will have signs or symptoms prior to the fainting episode. Diagnosis and treatment depends upon the cause of the fainting or syncope episode.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
Anorexia is an eating disorder characterized by markedly reduced appetite or total aversion to food. Anorexia is a serious psychological disorder and is a condition that goes well beyond out-of-control dieting. With anorexia, the drive to become thinner is actually secondary to concerns about control and/or fears relating to one's body. There are psychological and behavioral symptoms as well as physical symptoms of anorexia including: depression, social withdrawal, fatigue, food obsession, heart and gastrointestinal complications, kidney function, flaky skin, brittle nails, and tooth loss (this list is not exhaustive).
Chest pain is a common complaint by a patient in the ER. Causes of chest pain include broken or bruised ribs, pleurisy, pneumothorax, shingles, pneumonia, pulmonary embolism, angina, heart attack, costochondritis, pericarditis, aorta or aortic dissection, and reflux esophagitis. Diagnosis and treatment of chest pain depends upon the cause and clinical presentation of the patient's chest pain.
Internal bleeding occurs when an artery or vein is damaged and blood to escapes the circulatory system and collects inside the body. Internal bleeding can be caused by a variety of situations such as blunt trauma, deceleration trauma, medications, fractures, and spontaneous bleeding. Treatment of internal bleeding depends on the cause of the bleeding.
Sepsis (blood poisoning) is a potentially deadly infection with signs and symptoms that include elevated heart rate, low or high temperature, rapid breathing and/or a white blood cell count that is too high or too low and has more than 10% band cells. Most cases of sepsis are caused by bacterial infections, and some cases are caused by fungal infections. Treatment requires hospitalization, IV antibiotics, and therapy to treat any organ dysfunction.
Premature ventricular contractions (PVCs) are premature heartbeats originating from the ventricles of the heart. PVCs are premature because they occur before the regular heartbeat. There are many causes of premature ventricular contractions to include: heart attack, high blood pressure, congestive heart failure, mitral valve prolapse, hypokalemia, hypoxia, medications, excess caffeine, drug abuse, and myocarditis.
Heat stroke (heatstroke or sun stroke) is a form of hyperthermia. Heat stroke is a true medical emergency that can be fatal if not promptly and properly treated. Symptoms of heat stroke include: high body temperature, absence of sweating, with hot red or flushed dry skin, rapid pulse, difficulty breathing, strange behavior, hallucinations, confusion, agitation, disorientation, seizure, and coma. A victim of heat stroke must receive immediate treatment to avoid permanent organ damage.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Aortic valve stenosis is an abnormal narrowing of the aortic valve of the heart. The causes of aortic stenosis are wear and tear of the valve in the elderly, congenital, or scarring or scarring of the aortic valve from rheumatic fever. Symptoms include angina, fainting, and shortness of breath. Treatment is dependant upon the severity of the condition.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Encephalopathy means brain disease, damage, or malfunction. Causes of encephalopathy are varied and numerous. The main symptom of encephalopathy is an altered mental state. Other symptoms include lethargy, dementia, seizures, tremors, and coma. Treatment of encephalopathy depends on the type of encephalopathy (anoxia, diabetic, Hashimoto's, hepatic, hyper - hypotensive, infectious, metabolic, infections, uremic, or Wernicke's) are examples of types of encephalopathy.
Pericarditis is the inflammation of the pericardial sac that surrounds the heart. The causes of pericarditis include injury from heart attack, heart surgery, trauma; viral or fungal infection, HIV, tumors, mixed connective tissue disease, metabolic disease, medication reactions, or idiopathic. Treatment for pericarditis is generally medication, however, sometimes surgery is necessary.
Heat exhaustion is a milder form of heat-related illness that can develop after several days of exposure to high temperatures and inadequate or unbalanced replacement fluids. Warning signs of heat exhaustion include heavy sweating, paleness, muscle cramps, tiredness, weakness, dizziness, headache, nausea or vomiting, and fainting.
Myocarditis is an inflammation of the heart muscle and can be caused by a variety of infections, conditions, and viruses. Symptoms of myocarditis include chest pain, shortness of breath, fatigue, and fluid accumulation in the lungs. Treatment mainly involves preventing heart failure with medication and diet, as well as monitoring for heart rhythm abnormalities.
Plague is an infectious disease caused by the Yersinia pestis bacteria, which is primarily found in rodents the fleas that feed off of them. The bacteria are passed to humans through flea or rodent bites. There are three forms of plague: bubonic, septicemic, and pneumonic. The symptoms and method of transmission vary with each form of plague. Plague can be treated with antibiotics.
Orthostatic hypotension symptoms include lightheadedness, weakness, blurred vision, and syncope or passing out. Causes of orthostatic hypotension include dehydration, anemia, medication, blood loss, low blood pressure, heat related illnesses and more. Treatment of orthostatic hypotension depends on the underlying cause.
Renal artery stenosis is a narrowing of the diameter of the renal arteries. When the renal arteries narrow, the result is restricted blood flow to the kidneys, which may lead to impaired kidney function and high blood pressure (referred to as renovascular hypertension (RVHT). Renal artery stenosis can occur in one or both kidneys. The primary cause of renal artery stenosis is atherosclerosis. Risk factors for renal artery stenosis include high blood pressure, high cholesterol levels, age, cigarette smoking, and diabetes. Symptoms of renal artery stenosis include high blood pressure that does not respond to treatment, severe high blood pressure in individuals younger than 30 or greater than 50 years of age. Renal artery stenosis is diagnosed with imaging and functional tests. Treatment for renal artery stenosis include medication or surgery.
Toxic shock syndrome (TSS) is a condition caused by toxins formed by Staphylococcus aureus or group A Streptococcus bacteria. Signs and symptoms include fever, low blood pressure, rash, diarrhea, nausea, and vomiting. Left untreated, the patient will experience confusion, dizziness, headaches, seizures, and multiorgan failure. Treatment involves intravenous fluids and antibiotics, oxygen administration, surgery to drain the source of infection, and removal of tampons, nasal packings, or other sources of infection.
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