Friday Q&A: Low Blood Pressure (Hypotension)

Q: I've a question that I'm hoping you can address. I have low blood pressure and lately am finding that I am becoming VERY lightheaded moving from inversions, even simple ones like forward bend, to standing poses. I've spoken to my doctor about it and she has recommended the standard "eat move salt" approach, which I'm already doing. But I am wondering if there is any yogic therapy or advise for this issue?

A: You are not alone! I have students tell me they suffer from low blood pressure on a regular basis. Maybe “suffer” is not the right word, as some of these students don’t actually have any symptoms related to their lower than normal blood pressure, so they often just mention it in passing. But others will complain, as you are experiencing, of dizziness or lightheadedness with changing positions, especially when going from the ground to standing or inverted to upright positions.

To bring everyone up to speed, hypotension is usually defined as a blood pressure that is low enough to produce symptoms, which is usually below the numbers 100/70 when you get your blood pressure checked. Keep in mind that people in excellent aerobic condition, such as regular runners, will often have a resting blood pressure at or below this level. Of course, the blood pressure being a dynamic number that usually increases with increased demand on your body, like during a run, will rise to levels above the resting normal range without any untoward effects.

When someone has low blood pressure, as you do, and is having symptoms, it is wise to do a few things to rule out more worrisome causes, like check blood sugar to rule out diabetes, or check thyroid hormone levels to rule out an under-active thyroid gland. Other conditions to rule out are anemia, dehydration, or heart failure. To evaluate your heart itself if there is any suspicion of it being the source of your symptoms, you may be asked to get an ECG or heart tracing, an echocardiogram which uses sound waves to take moving pictures of the heart and valves, or even a cardiac stress test to see how your heart responds to increase demand via walking or running. And one final test, called a tilt-table test, can measure moment-by-moment changes in blood pressure as you are tilted up or down.This is ordered if your doctor suspects faulty brain signals (neurally mediated hypotension) as the cause of hypotension.

When symptoms are mild, the usual treatment is actually lifestyle/diet modifications, in the form of increasing salt in your diet, increasing water intake, wearing support stockings (which shunt blood from legs back to the heart, potentially increasing your blood pressure readings). If all else fails, there are several medications used to increase your blood pressure in order to see if your symptoms will resolve. According to the Mayo Clinic web site, there are several medications that are prescribed to raise the blood pressure:

“For example, the drug fludrocortisone is often used to treat this form of low blood pressure. This drug helps boost your blood volume, which raises blood pressure. Doctors often use the drug midodrine (Orvaten, Proamatine) to raise standing blood pressure levels in people with chronic orthostatic hypotension (which means hypotension that occurs due to change of position). It works by restricting the ability of your blood vessels to expand, which raises blood pressure.” 

As always, there are likely side effects to consider when deciding to try a medication for the symptoms.

Short of going through more testing, which might be a good idea in order to cover all your bases, is there anything that yoga might have to offer?  Well, one other recommendation the folks at Mayo Clinic offered may give you a way of coming out of forward folds that could impact your dizziness. In addition to moving slowly when going from supine or prone to standing, here’s what they suggest:

“if you begin to get symptoms while standing, cross your thighs in a scissors fashion and squeeze, or put one foot on a ledge or chair and lean as far forward as possible. These maneuvers encourage blood to flow from your legs to your heart.” 

The first suggestion sounds a lot like the leg position we use in Eagle pose (Garudasana).  You might try coming out of Standing Forward Bend (Uttanasana) with your legs crossed and squeezing as suggested and see if the dizziness lessens. The second suggestion sounds like Standing Leg Stretch (Padangustasana) done with a foot on a lift, such as we do onto a chair or top rung of a chair.  This later suggestion might be more applicable if your dizziness comes on when standing, as opposed to while changing positions. 

In addition to these ideas, you could carefully work with kumbhaka, or a hold at the top of the inhale, along with lengthening the inhale compared to the exhale. Start easy, with a one or two second hold. Try a 2:1 ratio timing for the inhale/exhale. This has a mild stimulating effect on heart rate and possibly blood pressure. You may want to practice these techniques separate from your asana practice, perhaps before starting. It might be possible to employ them during asana practice as well, although this is done less often, except in certain traditions, such as viniyoga or the yoga of Krishnamacharya.  So you could consider working with a teacher from those lineages. I hope this information is helpful.  I’d love to hear back if something improves, and all the best in resolving this situation!

—Baxter

So, what is blood pressure, anyway?

by Baxter

If you read yoga magazines or read online articles about yoga and your health, you often come across a warning to avoid this or modify that yoga asana if you suffer from high blood pressure or hypertension another term used for high blood pressure). But it turns out that there are a lot of differing opinions about how and what to change about a typical yoga practice if you have hypertension (HTN), and not a great deal of agreement on the best approach to take. However, before we get into that, I thought it would be helpful to discuss what blood pressure is, and how it is determined, as well as why HTN needs to be addressed either via lifestyle changes or medical intervention.

So, what is blood pressure? Well, it is a measurement we take—usually in your upper arm via a blood pressure cuff—that measures the pressure in the arteries of your arm. When you are sitting or standing with your arms at your sides, the place where blood pressure reading is taken is in line with your heart and its main artery, the thoracic aorta. Now we are measuring the pressure downstream in an artery in the arm, but it seems to correlate well with the pressures inside the heart and aorta. The top number of a blood pressure reading, called the systolic blood pressure, is the amount of pressure the blood in your arteries is exerting on the elastic, stretchy walls of the artery when the heart is at its maximum point of contraction. On average, it runs around 120mmHg’s of mercury in a normal healthy person. The bottom number, called the diastolic blood pressure, is the pressure at the time the heart is most relaxed between beats and is filling with more blood coming in from the body and lungs. A healthy average for that number is 80.  So, if your blood pressure, on average over the course of the day, is at 120/80 or below, it is said to be in the normal range.

Arctic Moon by Michele Macartney-Filgate

Via observations and studies, if your blood pressure averages 140/90 or above over the course of the day, you are said to have high blood pressure or hypertension. If you fall between 120/80 and 140/90, you are now said to have a condition called “pre-hypertension,” a no man’s land where it seems you are at a greater risk of developing HTN over time. More on HTN and why it’s important later.

Let’s go back to the concept of blood pressure for a few more moments. Your blood pressure is not a constant figure, but changes as your physical, mental and emotional activities change. It often goes up during exercise, stressful situations, and emotionally charged interactions, as well as varying with your body position of reclining, sitting or standing. It must vary dynamically to accommodate our changing situations throughout the day. Maintaining the proper blood pressure for our changing needs is a complex system that involves many of the body’s systems, including hormones, brain activity, and specialized receptors for pressure in the some of the biggest arteries in the body, called baroreceptors. As these various components of the blood pressure regulation interact, they result in dynamic fluid changes within the blood vessels and heart, via changing the blood flow in the vessels, the heart rate and the intensity of the contraction of the heart itself. Other organs also get involved, such as the kidneys, which are asked to help lower blood pressure at times by filtering out more water from the blood to decrease the overall amount of fluid in the system. Other parts of our nervous system can also influence the blood pressure readings. Your autonomic nervous system, composed of the two opposing and balancing parts, the sympathetic (Flight, Fight or Freeze response) and the parasympathetic (Rest and Digest response), can either increase or decrease your blood pressure, depending on how activated they are.

A few more thoughts on the general topic of blood pressure. Although we have defined the situation where blood pressure is elevated above the normal level and is considered potentially dangerous if left untreated, the opposite situation can also exist. That is, your blood pressure can be lower than normal, and this situation is called hypotension. Highly trained runners, especially long distance runners, can have blood pressures that average 100/60 or even lower and feel no worse for the wear. However, in other situations, hypotension can create symptoms that indicate it is not a normal adaptation to good aerobic fitness, such as lightheadedness, dizziness on standing and fainting. So next time, we will look at the conditions of hypertension and hypotension in more detail, and begin to discuss how yoga could fit into plan for better health for these students. Special thanks today to both Shari Ser and PubMed for their insights on blood pressure, as well as all my teachers back at UC College of Medicine in Ohio!