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Diagnosis
The diagnosis of orthostatic hypotension (OH) requires blood pressure (BP) readings while supine and upright, either during active standing or during a tilt-table test, to determine the presence of a sustained orthostatic fall of at least 20 mmHg systolic or 10 mmHg diastolic BP. BP and heart rate should be measured after the patient has been supine for several minutes and after standing still (or passively tilted) for 1–3 min. The changes in heart rate on standing help to determine whether the OH is neurogenic in origin. In patients with neurogenic OH (nOH) the increase in heart rate upon standing up is usually <20 bpm. Marked increases in heart rate suggest that the OH is non-neurogenic (Table 1).
Symptomatic or asymptomatic
Patients with nOH may or may not have symptoms. Symptoms of nOH typically disappear after the patient resumes the sitting or lying position because cerebral blood flow is restored to levels above the lower limit of autoregulatory capacity (Fig. 1). The chronic nature of nOH allows remarkable adaptive changes in cerebral autoregulatory mechanisms. Indeed, patients with nOH are frequently able to tolerate wide swings in BPs and often remain conscious at pressures that would otherwise induce syncope in healthy subjects [2, 5].
Management
The goal of treatment is not to normalize standing BP, but to reduce symptom burden, and to improve quality of life. The steps in management include: (1) correcting aggravating factors, (2) implementing non-pharmacological measures, and (3) drug therapies (Fig. 3).
Non-pharmacologic management
Non-pharmacologic management is vital and often underestimated to ameliorate the symptoms and severity of neurogenic orthostatic hypotenion (nOH). Patients and their families or caregivers should understand the basics of nOH pathophysiology and the importance of non-pharmacologic methods. In many situations, educational materials may be helpful for both the patient and the caregiver (Table 2). Physical inactivity and prolonged bed rest are common in patients with nOH. This leads to cardiovascular deconditioning further worsening the fall in BP and increasing symptoms leading to a vicious cycle (Fig. 4).
Pharmacologic treatments
The selection of one drug over the other is related not only to the severity of the patient’s symptoms, but also, in certain situations, based on the clinician’s preference and experience with a certain drug (Table 3).
Treatment of supine hypertension associated with neurogenic orthostatic hypotension
Hypertension in the supine occurs in ~50% of patients with nOH. There are no controlled clinical trials on its treatments. In patients with nOH experiencing supine hypertension [systolic blood pressure (BP) of 160–180 mmHg or diastolic BP of 90–100 mmHg], there is agreement that sleeping with the head of the bed raised at least 30°–45° should be recommended. If patients are experiencing sustained severe supine hypertension (systolic BP of >180 mmHg or diastolic BP of >110 mmHg) even after sleeping in the semi-sitting position, some experts advocate using short-acting an antihypertensive agent before bedtime (Table 4). This remains controversial and clinicians must be aware that pharmacological treatment for supine hypertension increases the risk of worsening hypotension and falls when the patient gets up at night or in the early morning.
References
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This manuscript is part of a supplement sponsored by Lundbeck.
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Dr. Kaufmann serves as a member of Advisory Board for Lundbeck and is Editor-in-Chief of Clinical Autonomic Research. Dr. Palma serves as a member of the Advisory Board for Lundbeck and is Managing Editor of Clinical Autonomic Research.
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Kaufmann, H., Palma, JA. Neurogenic orthostatic hypotension: the very basics. Clin Auton Res 27 (Suppl 1), 39–43 (2017). https://doi.org/10.1007/s10286-017-0437-3
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DOI: https://doi.org/10.1007/s10286-017-0437-3