Neurogenic Orthostatic Hypotension in Parkinson Disease: A Primer

Abstract

Parkinson disease (PD) is associated with a variety of motor and non-motor clinical manifestations, including cardiovascular autonomic dysfunction. Neurogenic orthostatic hypotension (nOH) is a potentially serious manifestation of cardiovascular sympathetic failure that occurs in approximately 30% of patients with PD. Here we review the pathophysiology and effects of the condition as well as treatment considerations for patients with PD and nOH. Screening for nOH using orthostatic symptom questionnaires, orthostatic blood pressure measurements, and specialized autonomic testing is beneficial for the identification of symptomatic and asymptomatic cases because cardiac sympathetic denervation and nOH can occur even at early (premotor) stages of PD. Symptoms of nOH, such as orthostatic lightheadedness, in patients with PD, have been shown to adversely affect patient safety (with increased risk of falls) and quality of life and should prompt treatment with nonpharmacologic and, occasionally, pharmacologic measures. Patients with nOH are also at increased risk of supine hypertension, which requires balancing various management strategies. Funding: Lundbeck (Deerfield, IL).

Autonomic Dysfunction in Parkinson's Disease

“…Orthostatic hypotension (OH) has been defined by consensus as a sustained decrease in systolic blood pressure of ≥ 20 mmHg or in diastolic blood pressure of ≥ 10 mmHg within 3 min of standing or at 60°or greater head-up tilt during formal tilt table testing [19][20][21]. Some centers, when performing tilt testing, utilize a systolic drop of ≥ 30 mmHg and a systolic drop of ≥ 15 mmHg as a cutoff because the tilt table eliminates the muscle pumping action of the legs that normally is present during active standing [21].…”

Diagnosis of Autonomic Disorders in Parkinson’s Disease

“…Udowodniono, iż ortostatyczne spadki ciśnienia tętniczego prowadzą do zwiększenia śmiertelności wśród pacjentów chorujących na chorobę Parkinsona [22]. Niedociśnienie ortostatyczne, podobnie jak i inne objawy dysautonomii, często pojawia się przed wystąpieniem objawów ruchowych, natomiast badania potwierdzają, że częściej występuje u chorych z dłuższym czasem trwania choroby [23]. Do najczęstszych objawów, jakie będą zgłaszać pacjenci z niedociśnieniem ortostatycznym, należą: zawroty i ból głowy, ciemnienie przed oczami, ogólne osłabienie.…”

A Call to Action: The Role of Healthcare Providers in Reducing the Burden Associated with Neurogenic Orthostatic Hypotension

“…For example, the potential contributing effects of any concomitant medications should be considered. Patients with PD and other synucleinopathies are often treated with medications such as levodopa (or other dopaminergic agents) and monoamine oxidase inhibitors that are associated with hypotensive effects and may worsen nOH symptoms [ 2 , 10 ]. Additionally, many other medications commonly used in older populations also have hypotensive effects, including drugs for hypertension, depression, erectile dysfunction, benign prostatic hyperplasia (BPH; alfuzosin or tamsulosin), or hair loss (minoxidil) [ 2 ].…”