Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review

Figures & data

Figure 1 Causes of OH.

Note: Data from these studies.^{2,3,10,21,80,81}
Abbreviations: nOH, neurogenic orthostatic hypotension; OH, orthostatic hypotension; PDE5, phosphodiesterase type 5.

Figure 2 Hemodynamics of postural change in healthy subjects and patients with nOH.

Note: Data from these studies.^18,82
Abbreviations: BP, blood pressure; HR, heart rate; NE, norepinephrine; nOH, neurogenic orthostatic hypotension.

Figure 3 Signs and symptoms of neurogenic orthostatic hypotension.

Note: Data from these studies.^1,18,21

Figure 4 Screening and diagnosis of nOH.

Notes: Key question and diagnosis are presented in bold. ^aAny positive response should prompt further investigations with BP measurements. Partial data from Freeman et al.¹ 10 OH/nOH Screening Questions (middle box) adapted from Gibbons CH, Schmidt P, Biaggioni I, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017;264(8):1567–1582. Creative Commons license and disclaimer available from: http://creativecommons.org/licenses/by/4.0/.²¹
Abbreviations: BP, blood pressure; bpm, beats per minute; HR, heart rate; nOH, neurogenic orthostatic hypotension; OH, orthostatic hypotension.

Table 1 Options for the management of OH/nOH

Recommendations for patients with OH/nOH
Concomitant medications
• Avoid or carefully manage medications that can cause or worsen symptoms of OH/nOH (Figure 1)
Compression garments
• Wear abdominal binders when out of bed
• Knee-high garments are not sufficient; must be at least thigh high to be effective (compression: 23–32 mmHg)
Dietary changes
• Adequate hydration: eight glasses of water daily, plus two additional 8-oz glasses before prolonged standing
• Increased salt intake: up to 2 additional teaspoons daily
• Avoid carbohydrate-rich meals and alcohol
“Head-up” rest/sleep position
• Expert clinical opinion: elevate head of the bed 6–9 inches to reduce risk of supine hypertension
Counter maneuvers
• Contract muscles below the waist for ~30 seconds at a time to increase BP when nOH symptoms occur
Low-impact exercise to improve physical conditioning
• Recumbent stationary bike, rowing machine, aquatic exercise
• Avoid exercises that
◦ Increase orthostatic stress (eg, treadmill)
◦ Increase risk of overheating or occur in hot environments
Pharmacotherapy
• FDA approved
◦ Droxidopa for nOH
◦ Midodrine for OH
• Off label
◦ Fludrocortisone
◦ Pyridostigmine

Note: Data from these studies.^21,49,51

Abbreviations: BP, blood pressure; FDA, US Food and Drug Administration; nOH, neurogenic orthostatic hypotension; OH, orthostatic hypotension.

Figure 5 24-Hour blood pressure variability in a patient with autonomic failure leading to daytime nOH and nighttime supine hypertension.

Abbreviation: nOH, neurogenic orthostatic hypotension.

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