Orthostatic Hypotension (OH)

Dual Pacemaker impanted about 9 months ago and have had bouts of orthostatic hypotension. My settings were adjusted from 50 bpm to 70 bpm and RR and its seems the OH has gotten worse. Today I measured my blood pressure after lying down and then standing up and it dropped from 120/66 (70 bpm) to 81/46 (80 bpm). Diagnostic for OH is only a drop in 20 mmHg

I wonder if anyone has any experience with OH. I found a case report that says that a male with OH was cured with a pacemaker and optimized settings. (https://www.sciencedirect.com/science/article/pii/S0019483212003070?via%3Dihub).

Thinking of asking to have HR setting reduced to 60 bpm. Always felt uncomfortable with big jump from 50 to 70. I have a regular cardioligist and a nurse who does the elctrical programming. May need an a electrocardiologist for any fancy adjustments on delays etc



Pacemaker for OH

by Penguin - 2023-03-01 07:39:26

Hi Bob, 

Thank you for your post and this interesting research article. You've learned about PMs very quickly to understand so much after just 9 months of pacing. Do you have a medical background - it's quite technical?

The most important part to note is probably at the end of the article. It states, 

'This case underlies the complex and multifactorial nature of orthostatic hypotension and the importance of a correct diagnosis of potentially correctable causes to treat a very disabling condition. Diagnostic and therapeutic work-up can be challenging and symptoms often persist despite traditional therapeutic options. In our case, an intervention that is not usual for the treatment of orthostatic hypotension (pacemaker implantation) allowed us to completely solve the problem because it addressed the physiopathologic mechanism (impaired cardiac filling due to very long PR interval). An extremely prolonged PR interval (like in our case) is not so common in clinical practice; moreover, RBBB and left axis deviation (in addition to first degree AV block) are a marker of extensive nodal and infranodal conduction system disease and they are additional factors for impaired hemodynamic state, because of a likely diffuse inter and intraventricular dyssynchrony. For these reasons, our findings cannot be extrapolated to other patients with isolated and less prolonged PR intervals (<300 msec).

I may be doing you a disservice here, but there are some very specific findings in this case. To understand how they might compare to your own situation would it be helpful to discuss the findings with your cardiologist in the first instance to be sure that it applies to you?

Re: the base rate adjustment from 50 bpm to 70 bpm. Have you gone back to your team to tell them how you feel and to document what is happening with your BP?  81/46 BP looks pretty significant IMHO.  You did well to capture a BP reading - clearly you didn't faint on that occasion! 

If you discuss the article with your cardiologist please let us know what he says and in the meantime I hope that you find some helpful treatments / adjustments to your PM. 



by bob53 - 2023-03-01 13:31:52

Hi Penguin,

Not in the medical field but work in science/tech. Just hoping to bumble my way through to at least finding the right questions to ask the doctors.

I did read that caveat on the case study and dont think that situation in particular applies to me but am open to hearing of perhaps other cases were people may have had a positive impact on their OH through PM adjustments. Unfortunately OH seems to be a rather tricky symptom to resolve. I have an appointment today and will report back any relevant info.



No problem

by Penguin - 2023-03-03 14:11:17

Yes, OH is a tricky one to resolve with a PM as the article suggests.

As a suggestion, have you tried contacting any of the syncope charities?  They have a lot of members with OH and hopefully they could come up with some helpful responses or at least support you.  My meagre knowledge on the subject is that medication to raise BP plus pacemaker is the usual combo suggested because BP has to be augmented. 

I think we all dig around for answers when things go wrong. Answers are harder to find than you hope sometimes.  These EPs have the qualification already - easier to ask them perhaps! 

Let us know how you get on. 

Best Wishes.

Orthostatic Hypotension too

by PLR - 2023-03-03 15:42:39

Hello, I too have OH even after pacemaker (June 2022). I am on fludrocortisone for the OH, but have actually had syncope even while on it. MRI showed pontine lacunar infarct, but MRI-A did not show any abnormalities. I have been ping-ponging between cardiology & neurology without any explanations as to why all of these things (including heart issues) seemed to happen all about the same time. So unfortunately I don't have any advice, but wanted to let you know you are not alone. Despite all of my test results, etc. I am functioning "normally" according to all who know me, and I run on my treadmill nightly. I am trying to accept that I may never have an explanation and I will likely be on multiple meds the rest of my life (I'm 60). Prior to all of this, I was an athlete, non-smoker, vegetarian without any known risk factors.


by bob53 - 2023-03-04 18:31:35

Thanks for the replies.

My cardiologist has me wearing compression stockings which seem to help. She doesnt think changing the pacemaker settings will effect the OH but left it to me if I want to change back down to 60 from 70. Will see how the compression staocking workout.

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