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Current management of orthostatic hypotension includes midodrine (A), steroids (B) and knee or thigh high stocking (C). There is no guideline or clinical clues when to use which and which combination.
Patients with diagnosis of orthostatic hypotension who arrived to the emergency room were enrolled and divided in 2 groups: Usual treatment (group 1) and patients in the study group (group 2). The patients in group 1 received the usual tests and treatment. The patients in group 2 received the new Expansibility of the Femoral Vein (EFV) test. The study group underwent the new Expansibility of the Femoral Vein (EFV) and had treatment based on its results. The EFV is the ultrasound study of the femoral vein examining its size and expansibility during strong cough. In general, the location of the femoral artery and vein to be checked is the sagittal plane immediately proximal to the bifurcation of the superficial and deep femoral artery. The size of the femoral vein is a little larger than the size of the femoral artery. If the size of the femoral vein during cough is 3 times larger than the one at baseline, the test is considered normal. If the size of the femoral vein is >3 times larger than then baseline, it is considered abnormal suggesting excessive venous pooling. If the femoral vein expands only <2 times of the baseline during cough, it is considered abnormal suggesting present or future pulmonary hypertension. If this test was done in conjunction with a right heart catheterization, then the femoral vein pressure at baseline and during cough is recorded.
15 patients were enrolled from January 2015 to April 2016. All came with evidence of orthostatic hypotension causing syncope. Quite a few patients (10/15) arrived while on full dose of midodrine and florinef. The results showed that 8/15 patients had abnormal EFV test with severe venous pooling. These patients improved well with thigh high ted hose.
The patients with orthostatic hypotension should have the EFV early and if the results are positive, the patient should wear thigh high stocking. Larger scale of clinical trial or registries of this new technique are needed.