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December 1, 2022

His blood pressure 'plunged' whenever he stood. Here's the 'far-fetched' reason why.

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    For years, doctors believed nerve problems were causing a 69-year-old man's rapid blood pressure changes and frequent fainting spells—until they removed a medical device that had been implanted in the man for over 15 years, Lisa Sanders writes for the New York Times Magazine.

    'He wouldn't stay upright for long'

    When a 69-year-old security guard stood up to patrol the entrance to the Veterans Administration Medical Center in Birmingham, Alabama, he started to feel "familiar symptoms he'd come to dread" in recent years, Sanders writes. The man's vision started to blur, he became lightheaded, he could feel his legs shaking—and he knew "he wouldn't stay upright for long."

    A few minutes later, the man was in the ED, where a nurse confirmed his previous diagnosis of orthostatic hypotension (OH). "When his blood pressure was measured while lying flat, it was normal," Sanders writes. "But it plunged when he sat up."

    As soon as the nurse helped the man stand, his blood pressure dropped so low he almost fainted. While he had been experiencing these symptoms off and on for a few years, they became worse over time.

    In recent months, when the man went to the ED a half-dozen times, doctors suggested several measures to mitigate his symptoms—but the only thing that helped was standing up slowly.

    Typically, the man was given intravenous (IV) fluids in the ED "to try to fill up a suspected empty tank," Sanders writes. However, IV fluids never seemed to help. "That made his doctors think that in his case the cause was neurogenic — his nerves weren't delivering their essential messages. And for this patient, that seemed a reasonable explanation, because it was clear that at least some of his nerves weren't working well," she adds.

    One doctor's 'far-fetched' theory

    After almost fainting at work, the man saw Matt Slief, a resident nearing the end of his first year of training. Following a quick evaluation, Slief left the patient to speak with Robert Centor, the attending physician.

    Once Slief finished explaining the patient's positional changes in blood pressure, Centor asked him, "What was his heart rate?" Slief told Centor that the patient's heart rate went up every time his blood pressure went down.

    "In that case, I doubt that his orthostatic blood pressure is caused by his nerves," Centor told Slief.

    In patients with neurogenic OH, the heart rate remains stable even after their blood pressure drops—and that isn't what happened with this man. At this point, no diagnosis seemed to fit.

    At their next meeting, Slief had come up with an alternate theory, but he was worried the idea "would sound far-fetched," Sanders writes.

    Years ago, the man had a filter put in the primary vein that brought blood from his legs to his heart to stop any clots that formed while he was in the hospital with a collapsed lung.

    While these filters are typically removed a few months after a patient's risk of clotting declines, many of them are not removed on schedule. And this man's filter was left in place for over 15 years.

    Slief suspected that "the filter had done its job and captured clots and they were now blocking the entire vessel," causing his positional hypotension, Sanders writes.

    Centor, who had been a doctor for 45 years, had never seen this happen—but he decided it was "worth considering," Sanders notes.

    'No weak legs, no lightheadedness, no falls'

    While there was no way to test Slief's theory, the team agreed that it made sense, Sanders writes. When they told the patient that the next step was to remove the filter, he "was eager to try."

    The patient's team reached out to Bill Parkhurst at the University of Alabama at Birmingham Hospital who specialized in this type of procedure. After a six-hour procedure, which required nine stents, Parkhurst removed the filter and restored blood flow between the man's legs and heart.

    "The first time the patient stood up after this procedure, he was amazed," Sanders writes. "The dizziness was gone."

    Four months later, the man's symptoms have not returned. "No weak legs, no lightheadedness, no falls," Sanders writes. "His feet are still numb, but he can live with that so long as they remain on the ground and he remains upright." (Sanders, New York Times Magazine, 11/30)

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