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Detecting nocturnal hypertension in Parkinson’s disease and multiple system atrophy: proposal of a decision-support algorithm


A pathological nocturnal blood pressure (BP) profile, either non-dipping or reverse dipping, occurs in more than 50 % of subjects diagnosed with multiple system atrophy (MSA) or Parkinson’s disease (PD). This may play a negative prognostic role in α-synucleinopathies, but, being mostly asymptomatic, remains largely underdiagnosed. In this proof-of-concept study, we aimed at developing a decision-support algorithm to predict pathological nocturnal BP profiles during a standard tilt-table examination in PD and MSA. Sixteen MSA and 16 PD patients underwent standard tilt-table examination and 24-h ambulatory BP monitoring (24-h ABPM). Clinical and tilt test differences between patients with a normal and a pathological nocturnal BP profile at 24-h ABPM were assessed, and a decision-support algorithm was developed accordingly. 75 % of MSA and 31 % of PD patients showed a pathological nocturnal BP profile. This was associated with more pronounced orthostatic BP drop (p = 0.03), joint occurrence of orthostatic hypotension and supine hypertension (p = 0.046), and lack of BP overshoot in the late phase II (II_L, p = 0.002) and in the phase IV (p = 0.007) of the Valsalva manoeuvre. Combined ∆BP ≤0.5 mmHg in the II_L and ≤−7 mmHg in the IV phase of Valsalva manoeuvre correctly predicted a pathological nocturnal BP profile with 87.5 % sensitivity and 85.7 % specificity. Pathological nocturnal BP profiles are associated with evidence of cardiovascular noradrenergic failure in PD and MSA. The Valsalva manoeuvre is routinely performed during standard tilt-table examinations. We propose the naked-eye evaluation of Valsalva phase II_L and phase IV BP behaviour as time-sparing screening tool for pathological nocturnal BP profiles in PD and MSA.

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Fig. 1
Fig. 2
Fig. 3


24-h ABPM:

24-h ambulatory blood pressure monitoring


Early phase II of the Valsalva manoeuvre


Late phase II of the Valsalva manoeuvre


Blood pressure


Heart rate


Orthostatic hypotension


Parkinson’s disease


Multiple system atrophy


Supine hypertension


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Conflicts of interest

Alessandra Fanciulli: the author declares no conflict of interest. Stefano Strano: the author declares no conflict of interest. Jean Pierre Ndayisaba: the author declares no conflict of interest. Georg Goebel: the author declares no conflict of interest. Laura Gioffrè: the author declares no conflict of interest. Massimiliano Rizzo: the author declares no conflict of interest. Carlo Colosimo: the author declares no conflict of interest. Carlo Caltagirone: the author declares no conflict of interest. Werner Poewe: has received consultancy and lecture fees from Abbott, Astra Zeneca, Teva, Novartis, GSK, Boehringer-Ingelheim, UCB, Orion Pharma, Merck Serono and Merz Pharmaceuticals in relation to clinical drug development programmes for PD. Gregor K. Wenning: the author declares no conflict of interest. Francesco E. Pontieri: the author declares no conflict of interest.

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Correspondence to Gregor K. Wenning.

Additional information

G. K. Wenning and F. E. Pontieri contributed equally to the work.

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Fanciulli, A., Strano, S., Ndayisaba, J.P. et al. Detecting nocturnal hypertension in Parkinson’s disease and multiple system atrophy: proposal of a decision-support algorithm. J Neurol 261, 1291–1299 (2014).

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  • Parkinson’s disease
  • Multiple system atrophy
  • Nocturnal hypertension
  • Orthostatic hypotension
  • Valsalva manoeuvre