Orthostatic hypotension: managing a difficult problem

Abstract

Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected individuals. Given the increased risk for cardiovascular events and falls, it is important to identify the underlying etiology of OH and to choose appropriate therapeutic agents. OH can be non-neurogenic or neurogenic (arising from a central or peripheral lesion). The initial evaluation includes orthostatic vital signs, complete history and a physical examination. Patients should also be evaluated for concomitant symptoms of post-prandial hypotension and supine hypertension. Non-pharmacologic interventions are the first step for treatment of OH. The appropriate selection of medications can also help with symptomatic relief. This review highlights the pathophysiology, clinical features, diagnostic work-up and treatment of patients with neurogenic OH.

Keywords:

• autonomic failure
• autonomic nervous system
• droxidopa
• multiple system atrophy
• orthostatic hypotension
• orthostatic intolerance
• Parkinson’s disease
• peripheral neuropathy

Financial & competing interests disclosure

This work was supported in part by National Institute of Health grants (R01 HL102387). SR Raj has worked as a consultant for Lundbeck Pharmaceuticals, GE Healthcare and Medtronic Corporation. He has also worked on clinical trials for Medtronic Corporation. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Orthostatic hypotension (OH) is a common cause of hospitalizations, particularly among the elderly and leads to significant morbidity and mortality when untreated.

• Patients with OH have increased risk of cardiovascular complications, including increased coronary artery disease, stroke and heart failure.

• OH can be classified as non-neurogenic (medications or volume depletion) or neurogenic OH (multiple system atrophy, Parkinson’s disease, Lewy body dementia or pure autonomic failure).

• Evaluation of these patients includes complete history and physical examination, detailed orthostatic vital signs and autonomic function testing.

• Patients with OH also may develop supine hypertension and post-prandial hypotension, which should properly be evaluated and treated to prevent complications.

• Non-pharmacological interventions, including patient education on the causes and triggers of OH, and are first line in the treatment of OH.

• Medications such as midodrine, fludrocortisone, droxidopa and pyridostigmine may provide additional symptomatic benefit to patients.

• High-quality studies of optimal treatments of OH are desperately needed.

Notes